Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

The use of fat grafting requires the surgeon to acquire
a new aesthetic appreciation of the aging process. A new
set of skills is required, including fat harvesting and
infiltration as well as management of unique complications.
Consequently, we advocate a conservative approach when
beginning to incorporate facial fat transfer in one’s
practice. In our experience, the postoperative surgical
morbidity rate increases as one pushes the limits of fat
transfer to obtain ideal results, particularly in the peri-
orbital region. Additional fat transfer in cases of under-
correction is an easier task when compared to the difficulty
of managing complications such as visible contour
irregularity or an overcorrected face. Conservatism,
particularly in the lower periorbital region, should be the
rule, especially for the surgeon inexperienced with facial
fat grafting.
The new aesthetic principles utilized in volume
restoration mandate a different approach to the patient.
Rather than arbitrarily defining an aesthetic objective, the
surgeon should try to aim at regaining the patient’s
youthful appearance. Many surgeons today evaluate a
patient during consultation and attempt to define what
areas of the face require improvement without reference
to how the patient actually looked when younger. For
instance, browlifting is usually recommended when the
brow appears ptotic. However, a patient may never have
had a well-defined upper-eyelid sulcus or arched eyebrow
position. At times, overelevating a brow can look
unnatural and may not return a patient to the way that he
or she looked when younger.19 Volume restoration may be
all that is necessary for a patient who always had a low-
lying brow that has lost its fullness with age. If the
patient’s brow was relatively higher in youth and now has
fallen, concurrent browlifting and fat grafting may be
emphasized. Patients are encouraged to bring in photo-
graphs of themselves when they were younger. These
photographs help the surgeon to learn more about the
patient’s youthful appearance and the patient to
understand the importance of volume loss in the aging
process. In any case, reviewing a patient’s old photo-
graphs has particular relevance and importance in order
to appreciate the role of fat grafting and help the surgeon
conceptualize the surgical plan.
Our approach for facial rejuvenation does not rely
solely on autologous fat transfer. We have entitled this
chapter “Complementary Fat Grafting” to emphasize the
complementary role that fat grafting plays in our clinical
practices (i.e., a patient’s aesthetic result and satisfaction
can be greatly enhanced by using a combination of
approaches such as fat grafting, facelifting, and blepharo-
plasty to attain the desired level of improvement).
Patients may be considerably more pleased when each
procedure adds to the tally of aesthetic improvement (Fig.
15-2). Traditional procedures and fat transfer need not be
248
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
Figure 15-1 Preoperatively this patient displays midfacial volume loss (A). Postoperative photo 1 year after autologous fat transfer (21 mL to cheek,
periorbital, and buccal regions, 15 mL to the perioral region, 10 mL to jawline) and a lower facelift (B). (From Lam S, Glasgold MJ, Glasgold RA: Complementary
Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
A
B

exclusive of one another. We can embrace two ideologies:
autologous fat transfer for volume depletion and lifting
procedures for gravitational descent. Judicious use of fat
grafting with select lifting procedures can constitute a
very potent mixture for correcting specific flaws of aging.
For example, prominently descended jowls and loose
platysmal bands cannot be adequately improved with fat
grafting alone. Standard cervicofacial rhytidectomy
combined with fat grafting of the prejowl sulcus is needed
to obtain the ideal aesthetic results. Combining pro-
cedures can also diminish perioperative morbidity; fat
grafting alone in areas that could be more easily targeted
with facelift procedures requires considerable volume,
adding to the already long recovery period necessitated by
fat grafting. The periorbital region is particularly
unforgiving. Selective blepharoplasty to reduce pseudoh-
erniated fat combined with fat grafting along the hollow
orbital rim provides the optimal balance of safety and
aesthetic benefit. In patients with considerable
pseudoherniated fat, the significant volume needed for fat
grafting can lead to patient dissatisfaction secondary to
increased likelihood for contour irregularity and overcor-
rection of the region. With ongoing clinical experience, a
surgeon will begin to perceive the complementary role
that volume enhancement can play in facial rejuvenation.
Although autologous fat has been used successfully to
manage hypoplastic lips and depressed facial lines (like
the nasolabial and labiomandibular folds), we strongly
believe that the rejuvenative benefit for these areas is
limited. Fat enhancement of the lips often requires sig-
nificant fat deposition with marked, prolonged ecchy-
mosis and edema with limited longevity. Similarly,
augmentation of the deeper lines in the perioral region
often fails to achieve adequate patient satisfaction. We do
infiltrate fat into the nasolabial folds when performing fat
augmentation of the cheek to ensure that the newly
augmented cheek does not exaggerate the apparent depth
of the nasolabial folds. Patients whose primary goal is lip
augmentation or effacement of facial lines are best treated
with one of the many available injectable fillers.
ANATOMY
The understanding of facial topography is the most
important aspect of anatomy as it relates to fat grafting.
The soft tissue loss that is associated with the aging
process is accentuated by the presence of facial retaining
CHAPTER 15
Complementary Fat Grafting
249
A
B
Figure 15-2 Preoperative (A) and 3-year postoperative (B) photos of a patient who underwent autologous fat transfer (27 mL to the cheek, periorbital,
and buccal regions) and facelift. (From Lam S, Glasgold MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright
Lippincott Williams & Wilkins.)

ligaments, which create unfavorable depressions (Fig.
15-3). Hills and valleys develop across the surface of the
face, contrasting the convexity associated with a youthful
appearance.
The face is usually divided into thirds for better
anatomic understanding. The upper third comprises the
brow and temple area and the middle third corresponds to
the cheek and midface. The lower third constitutes the
chin, prejowl, jowl, and lateral mandible. This systematic
appraisal will provide a concrete formula for specific
volume enhancement based on each individual anatomic
territory. Clinically relevant regions of each anatomic zone
will be emphasized with pearls to guide surgical strategy.
THE UPPER THIRD
The upper third of the face comprises three main
constituent elements: the brow, upper eyelid, and temple.
The brow remains one of the most easily targeted areas for
rejuvenation. The brow is defined by the hair-bearing
portion of the eyebrow and, more important, the soft
tissue that envelopes the lateral half of the superior orbital
rim. Placement of fat along this lateral half can restore the
desirable fullness that is lost during the aging process.
The upper eyelid and temple can also significantly hollow
with aging. In appropriate candidates, these areas can be
significantly enhanced with autologous fat grafting.
Surgical manipulation of this region should be reserved
for experienced fat-transplant surgeons due to the complex
anatomy and increased potential for complications.
THE MIDDLE THIRD
The middle third of the face is the most complex subunit
and perhaps the most important area for facial
rejuvenation with autologous fat grafting. This region
encompasses the lower eyelid and the malar and submalar
areas. A youthful face is characterized by a confluence of
the lower eyelid and cheek regions, which becomes
separated into visually distinct regions during the aging
process. The orbital rim is more clearly observed as a
separate entity from the cheek with aging due to the
orbital fat bulging superiorly and the cheek fat receding.
The voluminous lateral cheek mound of youth dissipates
to reveal the smaller, flatter contour of the malar bony
eminence that lacks any notable soft tissue coverage. The
anterior cheek begins to separate, often with a linear
depression that courses from the nasojugal depression
down inferolaterally to the buccal recess that corresponds
with the ligamentous attachment known as the malar
septum.20 Finally, the buccal region can exhibit marked
atrophy and should be reconstituted along with the
discussed anterior and lateral malar regions to achieve
better confluence and to avoid an exaggeration of buccal
hollowing following malar augmentation. As an extension
of the midface, the nasolabial fold should be deemed part
of midfacial volume enhancement.
THE LOWER THIRD
The lower third of the face is principally focused on the
labiomandibular fold, prejowl sulcus, labiomental sulcus,
and chin. The chin undergoes volume recession as
opposed to the volume gain that can be appreciated in the
jowl region. For very early jowling, volume enhancement
with autologous fat in the prejowl sulcus can be sufficient
to straighten the jawline. Even markedly conspicuous
jowling is often accompanied by proportionate volume
contraction along the prejowl region. Accordingly, face-
lifting to correct significant jowling can still fail to
250
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
Midface depression/malar septum
Nasolabial fold
Malar mound
Labiomandibular fold
Prejowl sulcus
Infraorbital rim
Figure
15-3 The
important
anatomic landmarks for fat injections
are depicted in this photograph.
(From Lam S, Glasgold MJ, Glasgold
RA: Complementary Fat Grafting.
Philadelphia, Lippincott Williams &
Wilkins, 2007. Copyright Lippincott
Williams & Wilkins.)

straighten the jawline if prejowl augmentation is not
performed. Volume deficiency in the lateral mandible,
posterior to the jowl, may be age related or congenitally
absent. The addition of volume to the lateral mandible
can help diminish the appearance of the jowl and restore
the youthful jaw contour.
PREOPERATIVE ASSESSMENT
The consultation for patients considering autologous fat
grafting is primarily based on sound facial analysis and
understanding the desires of the patient. Owing to the
complex and unconventional nature of autologous fat
grafting, patients may not entirely appreciate the benefits
of the procedure if they are more accustomed to
traditional surgical procedures such as facelifts and
blepharoplasty. Examining photographs from a patient’s
youth can significantly aid the surgeon in explaining the
aesthetic objectives of autologous fat grafting. Reviewing
with the patient each decade of change and showing the
gradual dissipation of soft tissue volume can be infor-
mative to most patients. Before-and-after photographs of
other patients who exhibit similar anatomy can also be
quite illuminating for a prospective patient. Digital
morphing technology often falls short of the intended
mark, as it is very difficult to convey volumetric changes.
After establishing realistic aesthetic objectives, the
surgeon must ensure that the patient fully comprehends
the benefits and limitations of the procedure. For
instance, fat grafting has proved to be less than ideal
to manage hypoplastic lips and deep nasolabial/
labiomandibular folds. In these areas, soft tissue fillers
may be a better solution.
SURGICAL TECHNIQUE
GENERAL CONSIDERATIONS
Autologous fat transfer can be undertaken with relatively
light intravenous sedation and infiltration of local
anesthesia. Preoperatively the patient’s face should be
marked carefully to delineate the recipient sites for fat
grafting. Markings should be made with the patient in an
upright position so that dependent tissues can help
accentuate the highlights and shadows of the face.
Determination of the appropriate donor site should also
be made in the preoperative area. In deciding on the
donor site, it is often helpful to ask patients where they
feel they accumulate the most fat or which area has been
the most recalcitrant to fat loss despite exercise. Prior
surgery, especially liposuction, can preclude the har-
vesting of usable fat from an area. Finally, the prohibitive
presence of occult or visible ventral hernias should be
ascertained before embarking on harvesting from the
lower abdomen.
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251
FAT HARVESTING
The areas that are typically available for fat harvesting
include the lower abdomen, inner thigh, outer thigh,
anterior thigh, lower lateral buttock, lateral waist, lower
back, inner knee, and triceps. The lower abdomen and
inner thigh tend to be the most favored sites for fat
harvesting, as the patient does not need to be repositioned
(Fig. 15-4A and B). With 10-mL Luer-Lok syringes
outfitted with a harvesting cannula, manual extraction of
the fat should be performed with only 1 to 2 mL of
negative pressure held on the plunger (Fig. 15-5). Entry
sites for cannula insertion through the skin are made with
a 16-gauge Nokor needle or a No. 11 blade in discreet
areas such as the umbilicus for the lower abdomen and
the inguinal line for the inner thigh. A gentle motion
should be carried out to harvest the fat and the depth of
the cannula should be at the midlevel of the fat pad. If
tenting of the skin is noted, then the surgeon is most likely
too superficial and risks the potential for a contour
irregularity at the donor site. Passage of the cannula too
deeply can elicit significant discomfort, especially in the
lower abdomen, when the cannula abrades the rectus
fascia. Harvesting uniformly over the entire area can
maximize fat yield and minimize contour irregularities.
Typically, owing to the presence of lidocaine, blood, and
lysed fat cells in the preprocessed syringe, the amount of
harvested fat should be anticipated to be about half the
collected volume, that is, 5 mL of fat per 10-mL syringe.
These estimates are important when calculating how
many milliliters of fat are needed for transfer. The total
volume of fat needed for transplantation will depend on
the surgeon’s clinical judgment and should be modified
for each patient. On average, 30 to 50 mL of fat is a common
amount for a semiconservative full-face fat transfer, with
over 60 mL representing a more aggressive strategy.
PROCESSING THE FAT
After each 10-mL syringe has been filled from harvesting,
it is sterilely passed to the surgical assistant who prepares
that syringe for fat infiltration. Although many techniques
exist for processing fat, we have relied on centrifugation
as our sole method. The assistant fastens a plug onto the
Luer-Lok end of the 10-mL syringe, removes the plunger
with the syringe in an upright position, and places a
specialized cap into the plunger side of the syringe. These
caps and plugs can be purchased from any reputable
manufacturer, but the original plunger and miniplastic
Luer-Lok cover that comes with the syringe should never
be used for centrifugation. After a balanced number of
syringes have been collected, they are inserted sterilely
into the centrifuge machine. Various types of systems are
available, each equipped with different inserts that can be
sterilized. The centrifuge is turned on to rotate for
approximately 3 minutes at 3000 rpm. A leeway of

1 minute and 1000 rpm can usually be permitted without
compromising the fat processing.
After the fat has been centrifuged, the syringe is
removed again sterilely and placed into a test-tube rack
resting on the sterile field. The processed syringe now
appears separated into three distinct layers: a supranatant
consisting principally of the oily residue of free fatty
acids, the central core of viable fat, and the infranatant
composed of blood and lidocaine (Fig. 15-6A). The cap
from the plunger side is always removed first to pour out
the supranatant (see Fig. 15-6B). Then, the plug is
unscrewed from the Luer-Lok side and the infranatant is
allowed to drain from below (see Fig. 15-6C). The syringe
is returned to the test-tube rack without cap or plug and
with the plunger side facing upward so that the fat does
not spill. Additional supranatant is wicked away by
placing an unfurled 4 × 4 cotton gauze into the exposed
plunger side of the syringe to make contact with the
column of fat (see Fig. 15-6D). It is very important that
the 4 × 4 gauze pad not be trimmed so as to prevent
introduction of particles of shorn cotton into the mixture
of fat intended for infiltration. After a few minutes have
transpired, the wicks are removed and the fat is trans-
ferred into the back end of a 20-mL syringe to facilitate
transfer into the 1-mL infiltration syringes (Fig. 15-7A).
The plunger of the 20-mL syringe is gently reinserted,
and a transfer hub is used to join the 20-mL syringe
with the 1-mL syringe via a Luer-Lok connection (see
Fig. 15-7B). The fat is then transferred to each 1-mL
syringe, one at a time. Generally, only four 1-mL syringes
are required; as the surgeon constantly infiltrates fat, the
assistant can reload the next syringe.
INFILTRATING THE FAT
The fat is always infiltrated with a 1-mL Luer-Lok
syringe so as to ensure placement of a very limited parcel
of fat per each passage of the cannula. Differential
placement of fat will optimize its viability and minimize
252
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
A
B
Figure 15-4 The donor sites for fat transfer
are shown. The most easily accessible areas are
in the abdominal and inner thigh regions (A).
Additional sites include the lateral thigh and flank
areas (B). (From Lam S, Glasgold MJ, Glasgold
RA: Complementary Fat Grafting. Philadelphia,
Lippincott Williams & Wilkins, 2007. Copyright
Lippincott Williams & Wilkins.)
Figure 15-5 Glasgold set of fat transfer instruments (Tulip Medical, Inc.,
San Diego, CA), from top to bottom: The 0.9-mm injecting cannula (4-cm
length) is good for periorbital injections, particularly when placing fat
superficially and for injection into the very fibrous recipient sites at the deep
lateral inferior orbital rim and lateral canthal region. The 1.2-mm injecting
cannula (6-cm length) is an all-purpose cannula that can be used for any
other injections. The 2.1-mm multiport harvesting cannula (12-cm length)
we have available as an alternative cannula for thin patients. The 3.0-mm
bullet-tip harvesting cannula (15-cm length) is our primary harvesting
cannula and can be used as one’s sole harvesting cannula. (From Lam S,
Glasgold MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia,
Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

complications. In areas that are less forgiving, such as the
periorbital region, 0.03 to 0.05 mL is injected per pass. In
more robust regions, such as the prejowl sulcus and mid-
face, 0.1-mL injections can be performed in each pass.
Only blunt injection cannulas should be used in order to
minimize the chance of nerve or vessel damage during
infiltration (see Fig. 15-5). A standard 18-gauge needle is
used to create the puncture site in the skin through which
the cannula tip is introduced. If considerable resistance on
the plunger is met when infiltrating fat, the cannula
should be withdrawn from the patient and cleared to
prevent inadvertent injection of a large bolus of fat.
Upper Third
The lateral half of the brow can be approached from
an entry site that is lateral to the lateral canthal tendon,
and filled to achieve a more robust, youthful contour
(Fig. 15-8A and B). A sausage-like shape can arise after
infiltration and should not raise alarm, as this will quickly
resolve postoperatively. Placement of the fat should be
relatively deep, ideally in the supraperiosteal plane. The
upper-eyelid recess corresponds with the inferior aspect of
the superior orbital rim. The “sunken eye” appearance
occurs in individuals who exhibit a very hollow upper
eyelid. This is an extremely difficult problem to correct.
CHAPTER 15
Complementary Fat Grafting
253
A
D
B
C
Figure 15-6 A shows harvested fat in 10 mL syringe pre- (left) and post- (right) centrifugation. In B, the surgeon pours off supranatant (free fatty acids).
In C, the surgeon drains infranatant (primarily blood). In D, the fat is wicked with gauze to remove residual supranatant. (From Lam S, Glasgold MJ, Glasgold
RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

Placement of fat along the inferior aspect of the superior
orbital rim can create a less hollowed-out appearance.
This maneuver is often accompanied by a protracted
period of swelling. Discussion with the patient about the
anticipated postoperative period is important in order to
establish realistic expectations.
The temple can also be an unforgiving area to
augment; therefore, only very small amounts of fat should
be delivered per cannula passage, as contour deformities
can readily arise in this area. We advise venturing to
correct the temple and hollow upper eyelid only after
adequate clinical experience has been acquired with fat
grafting elsewhere in the face.
Middle Third
Volume loss in the midface results in visible breakpoints
along the malar septum and between the lower lid and
cheek, imparting an aged and tired appearance. Often, the
midface is the most important region of the face to augment
with fat. Reestablishing a uniform and seamless contour
between the lower eyelid and cheek should be the principal
objective in many cases. Although infiltration of fat into the
precanine fossa and nasolabial fold is unlikely to efface a
deep nasolabial fold, it can create a better transition
between the newly augmented cheek and the upper lip.
The inferior orbital rim is one of the more difficult
areas of the face to enhance with fat and constitutes a
region where the majority of complications arise. Large
volume fat injection (greater than the recommended 0.03
to 0.05 mL per cannula pass) or placement of fat in a
superficial plane can increase the chance of a noticeable
irregularity postoperatively. Our complication rates have
dramatically reduced by approaching this region from an
inferior-based entry site (Fig. 15-9A and B). Using this
254
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
A
B
Figure 15-7 Processed fat is poured into a 20-mL syringe (A). The fat is then transferred to 1-mL Luer-Lok syringes through the attached transfer hub
(B). (From Lam S, Glasgold MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams &
Wilkins.)
A
B
Figure 15-8 A shows placement of fat along the lateral brow. B shows an intraoperative view of fat placement in the lateral brow in a supraperiosteal
plane. (A from Lam S, Glasgold MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams
& Wilkins.)

approach, the cannula tip passes perpendicularly to the
inferior orbital rim. This maneuver should be performed
with the index finger of the surgeon’s nondominant hand
placed on the superior aspect of the inferior orbital rim in
order to protect the globe. As one begins incorporating fat
transfer it is recommended that a conservative amount of
fat be placed along the inferior orbital rim (a total of
2 mL per side) in the supraperiosteal plane so as to
minimize contour problems. Larger volumes of fat can be
judiciously used in the more volume-deficient patients
with additional fat placed in a more superficial plane.
The lateral and anterior cheeks are easier areas to
augment. The cheeks can tolerate a more generous amount
of fat (0.1 mL per pass) in more superficial planes with-
out risking contour irregularities. The skeletonized lateral
cheek should be augmented to restore a youthful, full,
rounded contour that blends well with a full, anterior
cheek. The anterior cheek is typically divided by a linear
depression running from the superomedial nasojugal
groove inferolaterally to the buccal region. Placement of
fat into the anterior cheek should be principally situated
into the greatest areas of tissue loss, the depression at the
malar septum and the region inferomedial to the malar
septum. Passage of the cannula to reach the anterior
cheek can be made from a lateral cheek entry site, and the
cannula often must be forcefully pushed through the
fibrous malar septum to breach it (Fig. 15-10A and B). At
times, the malar septum does not pose much resistance
and can be easily traversed.
Patients should be evaluated for the presence of a
malar mound, which appears as a protuberance at the
junction of the anterior and lateral cheek lying just lateral
to the upper portion of the malar septum. When this
feature is present, the surgeon should attempt to avoid
placement of excessive fat under the already prominent
malar mound. Gentle contouring around the malar mound
can help soften the appearance of the malar protuberance
while at the same time rebuilding lost volume of the cheek.
If patients note a history of fluctuating, cyclic edema of the
malar mound, placement of fat immediately below this
structure may only worsen the condition and lead to a
protracted swelling in this area for several months.
In the thin patient, the buccal and submalar regions
are often hollow and can tolerate a generous amount of fat
with minimal concern of contour irregularity. Placement
of fat into the subcutaneous tissue and somewhat more
deeply will soften a gaunt appearance and provide a
better transition between the malar and submalar regions.
Finally, the precanine fossa (the triangular depression
circumscribed by the nasal ala medially and the upper
extent of the nasolabial fold laterally) and the nasolabial
fold are augmented not with the expectation of effacement
of the fold, but rather to achieve an improved transition
between the newly augmented anterior cheek and the
upper lip. A generous amount of fat can be placed into the
precanine fossa deeply into the supraperiosteal plane to
improve the hollowness in this area. The entire nasolabial
fold including the precanine fossa can then be augmented
from a perpendicular direction (i.e., from the lateral cheek)
into a more superficial subcutaneous plane.
Lower Third
The principal areas of the lower face that benefit from fat
augmentation are the prejowl sulcus, labiomandibular
recess, labiomental sulcus, lateral jawline, and anterior
central mentum. Of these three areas, the prejowl sulcus
CHAPTER 15
Complementary Fat Grafting
255
Figure 15-9 A shows placement of fat along the inferior orbital rim; the index finger of the surgeon’s nondominant hand protects the globe. B shows
an intraoperative view of fat placement along the inferior orbital rim. (From Lam S, Glasgold MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia,
Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
A
B

can be considered the most important for enhancement in
order to provide maximal straightening of a descended
jawline (Fig. 15-11). A generous amount of fat can be
placed into the prejowl sulcus without risking contour
deformity. Placement of fat should be made along both
the anterior and inferior aspects of the mandibular body
in order to achieve a three-dimensional, cylindrical
reshaping of the prejowl depression (Fig. 15-12A and B).
If the chin appears to benefit from mild projection, fat can
also be placed along the anterior chin to achieve the effect
of an augmentation mentoplasty. The lateral mandible is
augmented as needed, with placement of fat posterior
to the jowl so as not to accentuate the fullness. If a
concurrent rhyitidectomy is planned, fat should not be
distributed along the lateral mandible, as this area will be
undermined regardless of the type of facelift performed.
256
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
A
B
Figure 15-10 A shows the location and trajectory of the anterior cheek injection. In B, the intraoperative injection is performed. (A from Lam S, Glasgold
MJ, Glasgold RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
A
Figure 15-11 This patient had a facelift 7 years ago and is unhappy with her jawline (A). Her primary issue is volume loss in the prejowl sulcus. B shows
the results 1 year after isolated volume augmentation to the prejowl sulcus. (From Lam S, Glasgold MJ, Glasgold RA: Complementary Fat Grafting.
Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
B

POSTOPERATIVE CARE
At the end of the procedure, the patient does not require
any sutures, bandages, or drains of any kind unless a
concurrent lifting procedure was performed. The patient
is discharged after the appropriate interval of post-
anesthesia observance. Although some surgeons who
practice fat transfer do not believe in immediate
postoperative icing of transplanted regions owing to the
risk of reducing fat-cell viability, we believe that doing so
does not compromise the aesthetic result and can also
expedite the recovery. We advocate icing intermittently for
at least the first 48 to 72 hours postoperatively. Head
elevation is stressed for the first several nights after
surgery as it can reduce the extent of postoperative
edema. Although heavy exercise, especially with increased
intra-abdominal pressure and bending over, should be
avoided, a light isometric weight-lifting regimen with one
half to one third the typical weight and lighter cardio-
vascular exercise can be undertaken once the swelling has
begun to recede usually by the fourth or fifth post-
operative day. Besides these restrictions, there are no
limitations per se that prevent exercising areas of the body
that were used for donor harvesting. Finally, limiting salt
intake may minimize and assist in the resolution of
postoperative edema.
Although postoperative care is relatively simple and
straightforward, management of postoperative expecta-
tions may be more involved. Patients may perceive that
their face appears too inflated for their liking in the first
several postoperative weeks and regard this outcome as an
unintended result. Although the expected course of
recovery is explained in detail preoperatively, constant
reassurance should be proffered, with patients returning
as often as necessary. Ecchymosis and edema that accom-
pany fat grafting can be more pronounced than in
traditional surgical procedures, resulting in a social and
professional encumbrance for a longer period of time. The
periorbital region may be the most afflicted area with
bruising and soreness. In contrast to the face, where the
patient generally experiences very little discomfort, the fat
harvesting sites are generally more painful for the first
several days to weeks after surgery.
COMPLICATIONS
The complications that arise after fat grafting are
relatively unique compared with those that may arise
after traditional lifting procedures. Injuries to nerves or
vascular structures are extremely rare. The more common
problems with fat transfer arise from contour irregularities
(“lumps” or “bulges”) and over- or undercorrection. A
systematic appraisal of the problem and targeted
correction for each individual problem should be under-
taken in every case.
“Lumps” present as small discrete areas of excessive
fat, and are most likely to occur in the periorbital region.
Conservative placement of fat in the periorbital region is
an important step in avoiding this problem. When a lump
does occur, treatment begins with steroid injections into
the area of concern. If this fails to correct the problem,
and there appears to be a relatively discrete lump of fat,
directly excising this can alleviate the contour deformity
(Fig. 15-13).
“Bulges” are wider areas of elevation and may
represent persistent edema or induration, or in some cases
a large uneven placement of fat. Bulges present as
thickened areas, which can be palpated and seen along
the inferior orbital rim. Injection with conservative amounts
CHAPTER 15
Complementary Fat Grafting
257
Figure 15-12 A depicts the location and trajectory of the prejowl injection. In B, the intraoperative injection is performed. (A from Lam S, Glasgold MJ,
Glasgold RA: Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
A
B

of triamcinolone acetonide in increasing strengths from
10 mg/mL to 40 mg/mL have proved beneficial in most
circumstances but must be repeated every 1 to 2 months
until resolution. In our experience direct liposuction of
these areas has not been successful.
Overcorrection implies that a generalized region has
been overly inflated beyond the patient’s expectations. As
mentioned, the first several weeks to months are marked
by ongoing resolution of tissue edema. Therefore, a
conservative, expectant approach is advocated. If failure
of timely resolution of the problem is encountered, then
microliposuction with an 18-gauge Klein Capistrano
cannula can be performed to reduce volume.
Undercorrection remains the most favorable com-
plication, as it represents the most easily correctable
condition. Additional fat harvesting and infiltration can
be accomplished relatively quickly and without difficulty
under local anesthesia or limited intravenous sedation.
258
Samuel M. Lam • Mark J. Glasgold • Robert A. Glasgold
Figure 15-13 Preoperative view (A) of a patient who underwent fat transfer
to the inferior orbital rim and cheek. Six months postoperatively, the patient has
good malar augmentation but persistent visible lumps at the central inferior
orbital rim (B). This patient was also unhappy with persistent lower lateral fat that
had not been removed. After correction of these problems with direct excision
of redundant lower lid skin and excess fat through an incision placed in the
crease following the inferior orbital rim (C). The lateral fat pad was reduced
through a transconjunctival approach. (From Lam S, Glasgold MJ, Glasgold RA:
Complementary Fat Grafting. Philadelphia, Lippincott Williams & Wilkins, 2007.
Copyright Lippincott Williams & Wilkins.)
A
B
C

Future Considerations
We are standing at the crossroads of a major paradigm
shift from excision-based surgery to volume
enhancement. Whether or not there will be an increasing
shift away from excisional surgery in favor of volume
correction is yet to be determined. We advocate a
combination approach that requires judicious selection of
lifting procedures and fat grafting tailored to each
individual. Whatever the outcome, it appears that fat
grafting and facial volume enhancement represent the
present and future of facial rejuvenation, as we see it
from the narrow vantage of today’s prism.
As we still have yet to find the perfect facial filler, the field
of synthetic facial injectables continues to advance at a
dizzying pace. Just a few years ago, bovine collagen was
the only Food and Drug Administration (FDA) approved
synthetic filler. Today, we have a multitude of choices that
continue to grow, as FDA approval marches forward.
Every type of filler carries specific characteristics that
make it more ideal for a certain clinical application and
also drawbacks that may hinder implementation. The
continuing change in the landscape of facial fillers offers
the possibility for volume augmentation procedures with
less downtime and without the need for harvesting fat.
We predict that volume enhancement will continue to
play an increasing role as both a complementary and a
stand-alone procedure in facial rejuvenation.
REFERENCES
1. Neuber F: Fettransplantation. Chir Kongr Verh Dtsch Ges
Chir 1893;22:66.
2. Czerny M: Plastischer ersatz der brusterlruse durch ein lipom.
Verh Dtsch Ges Chir Zbl Chir 1985; 27:72–75.
3. Lexer E: Freie Fettransplantation. Dtsch Med Wochenschr
1910;36:640.
4. Bruning P: Cited by Broeckaert TJ, Steinhaus J: Contribution
a l’étude des greffes adipueses. Bull Acad R Med Belg
1914;28:440.
5. Tuffier T: Abces gangreneux du pouman ouvert dans les
bronches: hemoptysies repetee operation par decollement
pleuro-parietal; guerison. Bull Mem Soc Chir Paris
1911;37:134.
6. Straatsma CR, Peer LA: Repair of postauricular fistula by
means of a free fat graft. Arch Otolaryngol 1932;15:620-621.
7. Peer LA: The neglected free fat graft. Plast Reconstr Surg
1956;18:233.
8. Peer LA: Loss of weight and volume in human fat grafts. Plast
Reconstr Surg 1950;5:217.
9. Shiffman MA (ed): Autologous Fat Transplantation. New
York: Marcel Decker, 2001.
10. Bircoll M: Autologous fat transplantation. The Asian Congress
of Plastic Surgery, February 1982.
11. Illouz YG: The fat cell graft: A new technique to fill
depressions. Plast Reconstr Surg 1986;78:122-123.
12. Krulig E: Lipo-injection. Am J Cosmet Surg 1987;4:123-129.
13. Newman J, Levin J: Facial lipo-transplant surgery. Am J
Cosmet Surg 1987;4:131-140.
14. Shu T, Lam SM: Liposuction and lipotransfer for facial
rejuvenation in the Asian patient. Int J Cosmet Surg Aesthet
Dermatol 2003;5:165-173.
15. McCurdy JA Jr, Lam SM: Cosmetic Surgery of the Asian Face,
2nd ed. New York: Thieme Medical Publishers, 2005.
16. Coleman SR: Structural Fat Grafting. St; Louis: Quality
Medical Publishers, 2004.
17. Amar RE: Adipocyte microinfiltration in the face or tissue
restructuration with fat tissue graft [In French]. Ann Chir
Plast Esthet 1999;44:593-608.
18. Lam SM, Glasgold MJ, Glasgold RA: Complementary Fat
Grafting. Philadelphia: Lippincott, Williams, & Wilkins, 2007.
19. Schreiber JE, Singh NK, Klatsky SA: Beauty lies in the
“eyebrow” of the beholder: A public survey of eyebrow
aesthetics. Aesthet Surg J 2005;25(4):348-352
20. Mendelson BC, Muzaffar AR, Adams WP: Surgical anatomy of
the midcheek and malar mounds. Plastic Reconstr Surg
2002;110(3):885-896.
CHAPTER 15
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259

HISTORY
Lasers and injectables are the two fulcra around which
noninvasive facial rejuvenation navigate. Historically, the
use of lasers in cosmetic medicine can be traced to Leon
Goldman in the 1950s.1-3 Although the ruby laser was the
first medical laser developed, it was the argon laser that
began a practical clinical application in the early 1970s
with the removal of decorative tattoos.4-7 These lasers did
not achieve widespread use because of significant com-
plications, but they heralded the modern era for non-
invasive facial rejuvenation. Despite the exciting
discoveries in the field, Goldman’s national lectures did
not draw copious attendees because of the lack of clinical
relevance of these devices. In the ensuing 25 years, how-
ever, the carbon dioxide (CO2) and erbium:yttrium
aluminum garnet (Er:YAG) lasers have gained significant
acceptance by allowing a well-controlled skin resurfacing
modality with superior aesthetic outcome and limited
complications. In the 1990s, “nonablative lasers” also
became available, providing a no-downtime solution for
treating minimal to moderate rhytids.
The birth of facial fillers could be dated back many
decades to the use of fat and fascia lata transplants. The
availability of bovine collagen (Zyderm and Zyplast,
Inamed Aesthetics, Santa Barbara, CA), however, began
the modern era of injectable fillers. These two products
were designed in the mid-1970s and have been the “gold
standard” to which other fillers are compared both in
clinical practice and in Food and Drug Administration
(FDA) trials. It is only since 2000 that other injectables
have seriously challenged collagen’s dominance with the
availability of botulinum toxin type A (BTX-A), stabilized
hyaluronic acid products, polymethyl methacrylate micro-
spheres (PMMA), synthesized calcium hydroxylapatite
(CaHA), and injectable poly-L-lactic acid (PLA). The
continued popularity of BTX-A and longer-acting fillers
have transformed our approach to facial rejuvenation.
Unlike ablative laser and chemical resurfacing, these
products truly allow the patients to obtain immediate
facial enhancements with limited downtime.
PERSONAL PHILOSOPHY
The road to facial rejuvenation always starts with the
diagnosis. Once the diagnosis is established, the therapy is
naturally born. In evaluating the aging face one may see
aesthetic pathology in three broad terms: laxity (type A),
furrowing (type B), and rhytids (type C).8 Rhytids are
superficial cutaneous wrinkles, whereas furrows are
deeper valley-like expression lines (Fig. 16-1). Other
issues contributing to an aged appearance include color
irregularity and loss of skin luster. The interplay among
various aging processes often makes it impossible to
obtain complete therapeutic effect from any one modality.
Examples include unsightly nasolabial folds or marionette
lines remaining after rhytidectomy or poor resolution of
crow’s-feet after periorbital laser resurfacing. Indeed,
every face is unique with elements of aging and every area
may have several pathologies contributing to the aging
problem. As a result, noninvasive techniques are of great
value for some aging defects but not for others. Skin and
muscle laxity of more than a moderate degree requires
surgical intervention whereas fine rhytids and furrowing
are preferentially treated by lasers or noninvasive
injectables, respectively. In this chapter, I will discuss my
preferred nonsurgical techniques for facial rejuvenation.
ANATOMY
Different aesthetic deficiencies warrant distinctive therapies.
Although a given area of the face can present with
different issues in diverse individuals, there are recurrent
patterns for each facial area. Figure 16-1 reveals the most
frequently encountered aging changes in each area of the
face. Periorbital aesthetic pathology includes crow’s-feet
furrows or rhytids, lower eyelid rhytids and furrows, lower
lid laxity, fat pad herniation, tear-trough depression,
darkness in the skin, dermatochalasia of the upper lids,
and brow ptosis. The forehead most commonly ages with
ptotic brows and the development of expression furrows.
Horizontal forehead furrows develop secondary to
Nonsurgical Facial Rejuvenation
Douglas Hamilton, MD
261
C H A P T E R S I X T E E N

frontalis muscle activity. Glabellar furrows occur because
of corrugator and procerus muscle contraction. In
females, these lines may be superficial enough to classify
them as rhytids.
In the midface, laxity of the cheeks and progressive
volume loss are often readily apparent. The salient mani-
festation of the cheek and facial tissue laxity is mandibu-
lar line blurring, jowl formation, and accentuation of
nasolabial folds. Perioral changes due to bone and teeth
movement along with recurrent facial expressions most
often develop furrows: nasolabial, marionette (below the
mouth commissure), and lip lines. True intracutaneous
rhytids of the upper lip must be treated differently than
furrows. Upper lip furrows are rarely seen in men whereas
about 70% of women will exhibit significant muscle
movement of the upper lip when speaking, therein leading
to these musculocutaneous furrows. The cheek region
may develop laxity as well as rhytids.
PREOPERATIVE ASSESSMENT
The preoperative analysis for noninvasive facial reju-
venation includes a thorough history and physical exam-
ination. Patients with history of collagen vascular disease
(systemic lupus, scleroderma, and keloid formation),
vitiligo, isotretinoin (Accutane, Roche, Nutley, NJ), and
radiation therapy are cautioned about laser and chemical
resurfacing. Isotretinoin and radiation therapy destroy the
adnexal structures that are necessary for epithelial
regeneration after skin resurfacing. We like to wait at least
12 months after the discontinuation of isotretinoin to
proceed with laser resurfacing. Patient skin classification
is also important in the preoperative analysis, especially
for those who are being considered for laser resurfacing.
We utilize the Fitzpatrick scale (Table 16-1) to determine
patient suitability for ablative laser resurfacing.9,10
Generally, patients who are at the extremes of the
Fitzpatrick scale are unsuitable candidates (types I, IV, V,
and VI). Type I patients are at risk for hypopigmentation,
which can be an extremely difficult complication to correct.
Patients who are darker are at risk for hyperpigmentation
that usually can be treated successfully with topical
creams although the wait can be an anxious one for
physician and patient alike. Nonablative lasers are
suitable for all patients. The Glogau classification can
also be useful for evaluating appropriate candidates (Box
16-1). This classification system focuses on the degree
and type of wrinkles and the effects of photoaging.11
After the general skin survey, we perform our facial
analysis based upon three major categories of defects:
laxity (type A), furrowing (type B), and rhytids (type C).
Proper analysis allows us to bring patients into an
understanding of what treatments will be required for
their type of facial aging. The categorization firmly roots
the credibility of the physician’s choice of procedure and
262
Douglas Hamilton
Brow laxity
Horizontal furrows
Glabellar furrows
Rhytids
Laxity
Color irregularities
Nasolabial furrows
Upper lip furrows
Marionette furrows
Figure 16-1 The aging process. Three broad
pathologic changes occur during the aging process:
laxity (type A), furrowing (type B), and rhytids (type C).
Table 16-1
Fitzpatrick Classification System
Skin Type
Skin Color
Reaction to Sun
Type I
Very white or freckled
Always burns
Type II
White
Usually burns
Type III
White to olive
Sometimes burns
Type IV
Brown
Rarely burns
Type V
Dark brown
Very rarely burns
Type VI
Black
Never burns

the patient’s confidence in the decision. Moderate to severe
facial laxity, brow ptosis, and eyelid dermatochalasia require
surgical intervention. Periorbital dynamic furrows
generally require chemodenervation of the offending
muscles with BTX-A. Occasionally, deep furrows in the
glabellar region will require BTX-A and fillers to enhance
the overall results. Perioral furrows such as nasolabial
folds, marionette lines, and smoker’s lines can be
successfully treated with fillers. In appropriate patients,
periorbital and perioral rhytids can also be treated
successfully with laser resurfacing. Chemical peels can play
an important role in nonsurgical facial rejuvenation in a
similar manner to laser resurfacing.
ABLATIVE LASER RESURFACING
Laser resurfacing is a powerful tool that gives the surgeon
precise control over the depth of ablation and the potential
outcome. Laser facial rejuvenation can be broadly
classified into two major divisions: ablative and
nonablative. Ablative laser resurfacing techniques most
commonly utilize the CO2 and Er:YAG lasers (Fig. 16-2).
The CO2 laser (10,600 nm wavelength) vaporizes water
containing skin tissue, resulting in thermal injury and
tissue vaporization. By pulsing the delivery of the CO2
laser, newer systems are able to vaporize the epidermal
and dermal region without causing significant residual
thermal damage.12 Each pass of the CO2 laser will ablate
20 to 100 μm of tissue (depending on the fluence) with
150 μm of residual thermal damage. The Er:YAG laser
(2940 nm wavelength) is also absorbed by water, albeit at
12 to 18 times the efficiency of the CO2 laser. At a fluence
of 5 J/cm2, the Er:YAG laser will vaporize about 5 to
20 μm with minimal residual thermal injury. As a result,
the skin reepithelializes more rapidly and the postoperative
course is shorter with Er:YAG laser resurfacing.
Clinically, I have seen two phases of rejuvenation
with ablative laser resurfacing. The first phase is the
immediate improvement in wrinkles that disappears
within 2 to 3 months. A second phase begins in the ensuing
months with “reimprovement” of rhytids and tightening
of the skin. My experience with ablative lasers over the
past decade in close to 1000 patients suggests that CO2
and Er:YAG achieve comparable results. If Er:YAG
treatment entails a high number of passes (greater than
five), its depth of injury is similar to that of CO2 lasers.
CHAPTER 16
Nonsurgical Facial Rejuvenation
263
Box 16-1
Glogau Photoaging Classification System
Type I: Mild
■
28–35 years old
■
“No wrinkles”
■
No keratosis
■
Requires little or no makeup
Type II: Moderate
■
35–50 years old
■
“Wrinkling in motion”
■
Shallow complexion with early actinic keratosis
■
Requires minimal makeup
Type III: Advanced
■
50–60 years old
■
“Wrinkles at rest”
■
Discoloration of the skin with telangectasias and actinic
keratosis
■
Always wears makeup
Type IV: Severe
■
Over 60 years old
■
“Only wrinkles”
■
Photoaging, gravitational and dynamic forces affecting
skin
■
Actinic keratosis with or without cancer
■
Wears makeup with poor coverage
A
B
Figure 16-2 Preoperative (A) and postoperative (B) photographs of a patient who received ablative laser resurfacing.

Laser resurfacing is indicated for patients with perioral
and periorbital rhytids, furrows, mild lower eyelid derma-
tochalasia, actinic changes, and facial elastosis. Preoperative
preparations include 2 to 4 weeks of tretinoin (Retin-A)
and hydroquinone application to speed epidermal
migration and reduce postoperative hyperpigmentation.
Patients are routinely prescribed acyclovir 3 days before
and cefuroxime beginning 12 hours before surgery. Full
face procedures are performed under conscious sedation
with regional nerve blocks. Halcion has been used orally
in place of IV sedation in some cases. Regional procedures
generally require only nerve blocks.
The CO2 laser is performed on surgically prepped
skin that is then immaculately dried. With the Ultrapulse
CO2 laser (Lumenis, Santa Clara, CA), I use a setting of
300 mJ at a fluence of 5 J/cm2 with a rectangular pattern.
The white char is removed using wet gauze and the face
is dried again. The first pass generally removes about 60
to 100 μm of tissue reaching the superficial dermis.
Pinpoint bleeding may begin depending upon the area of
the face. A second pass at this setting is required if
collagen remodeling and substantial long-term benefits
are to be achieved. It is on the second pass that the long-
term aesthetic results of laser resurfacing are observed
with the ablation of the shoulders of the wrinkles and
collagen contraction. The latter can be quite dramatic to
any observer. Even though further beneficial effects may
be achieved by a third pass, many experienced laser
surgeons avoid further passes while treating the eyelids or
upper lips. I have routinely used a spot third pass in both
of these areas without adverse sequelae. One wants to
avoid a grayish hue, which indicates imminent pene-
tration of subcutaneous fat. After a final removal of char,
I apply refrigerated Vigilon (C.R. Bard, Murray Hill, NJ)
and the patient is discharged. The Vigilon is removed in
24 to 48 hours by the nursing staff.
Postoperative care after bandage removal entails
alternating cold vinegar and water soaks with the
application of plain Aquaphor (Beiersdorf AG, Hamburg,
Germany). Local débridement of crusts and copious use
of Aquaphor create a clean and moist environment, which
speeds up the healing process and epidermal cell
migration. The patients are able to apply make-up once
the skin has re-epithelialized within 7 to 10 days. Patients
must be warned about postoperative erythema, which can
persist up to 6 to 8 weeks.
Adverse sequelae resulting from ablative laser resur-
facing include infection (usually candidiasis), hypopig-
mentation, persistent erythema, and elevated scars
(normally seen after extended erythema). Hyperpig-
mentation, which occurs more frequently in darker-
skinned (Fitzpatrick type IV to VI) individuals, usually
resolves with medical management. Hypopigmentation
more frequently affects individuals with fair skin
(Fitzpatrick type I). Hypopigmentation, a less common
complication, can be a serious adverse outcome, as the
skin rarely repigments to its normal color. Therefore, the
higher risk candidates for adverse pigmentation issues are
lighter skinned individuals. Strict perioperative protocols
virtually eliminate persistent postoperative erythema and
elevated scars.
Although the introduction of collagen provided a
foreshadowing of nonsurgical procedures, it was the
advent of the CO2 laser resurfacing that ushered in the
modern era of noninvasive technologies by the virtue of its
remarkable aesthetic outcome. The demand of laser
resurfacing has waned over the past few years, as it is now
perceived by patients as being too invasive.
NONABLATIVE LASER RESURFACING
Nonablative lasers such as the N-lite (ICN Photonics, UK)
and Cool Touch (Cool Touch Corp., Roseville, CA) have
been developed with the intent to stimulate and remodel
collagen without significantly injuring the epidermis. With
multiple treatments, nonablative lasers can clinically
reproduce in a limited manner the second phase of skin
remodeling that is seen with ablative lasers. Nonablative
lasers do not produce any collagen contraction and
therefore cannot cause localized tightening of tissue (e.g.,
lower eyelids). The most clinically studied nonablative
laser is the Cool Touch. Cool Touch is a pulsed
neodymium:yttrium-aluminum-garnet laser (Nd:YAG;
1320 nm wavelength) that has a fiberoptic hand piece
coupled to a thermal sensing cryogenic spray. The
coupling of Nd:YAG to a cooling system allows delivery of
thermal energy to the dermis while preventing epidermal
thermal damage.13
This laser can be used on all skin types.14 Pre-
operative preparation is not necessary, although local
anesthesia may be required for certain patients. The
treatment technique is very simple. The laser utilizes
minimally overlapping nonstacking pulses. Stacking the
pulses will abort the desired collagen synthesis. The
patients will typically require multiple treatments. Each
additional treatment improves the depth of the wrinkles,
which may be seen as early as 1 month after the first
treatment. Treatment intervals can be as short as 2 weeks,
although 3 to 6 months is the most common, because
collagen synthesis appears to continue for 6 weeks after
each session. The most common indication for this
treatment modality is improvement of fine periorbital and
perioral rhytids. There is no associated pain and minimal
postoperative care and complication (Fig. 16-3).
CHEMICAL PEELS
In the 1990s chemical peeling relinquished much of its
application to the CO2 and erbium lasers. Lasers are
perceived to provide superior control to the physician,
264
Douglas Hamilton

resulting in more predictable results. Chemical peels,
however, do have certain well-clarified indications and
can serve as an important tool in an aesthetic practice.
Medium to deep peels cause a chemical necrosis at the
papillary to reticular dermal level, while the superficial
peels generally affect the epidermal stratum corneum.
SUPERFICIAL PEELS
Superficial peels include glycolic (alpha hydroxy) and
beta hydroxy acids. They function in a similar manner to
microdermabrasion by improving the skin’s overall
appearance. Superficial peels remove stratum corneum
and even out cutaneous pigmentation. Glycolic peel prepa-
rations vary widely, and one should become accustomed
to a single brand because variations in concentration and
pH cannot be readily transposed from one proprietary
peel to another. Additionally, practitioners must under-
stand the other variables that would affect the depth of
penetration and the ultimate outcome (i.e., pre-peel
treatment with retinoic acid, duration of application, the
physical pressure of the Q-tip at the time of peel, length
of time that chemical is left on before dilution with water
or bicarbonate).
MEDIUM PEELS
The classic medium-depth peel is trichloracetic acid
(TCA). Previously, 50% concentration was used but in
recent years a 35% concentration immediately following a
superficial peel (CO2 ice or Jessner’s peel) has become
popular because it reduces side effects while maintaining
efficacy. Rhytids can be improved by medium-depth peels
CHAPTER 16
Nonsurgical Facial Rejuvenation
265
but not superficial peels. The histologic effects of
medium-depth peels extend just short of the junction of
the papillary and reticular dermis.
DEEP PEELS
Deep peels are performed with phenol, usually 88%
mixed with croton oil (Baker’s formula). The croton oil
may play more of an active role than previously
suspected. Injury extends to the reticular dermis with a
healing period of 7 to 10 days. Phenol peels can
significantly improve rhytids. Pigmentation changes
however are common. Deep peels must be performed by
experienced physicians in a controlled environment and
under sedation. Phenol peels can potentially cause sig-
nificant cardiac and renal toxicity. Cardiac complications
can be avoided by hydrating the patient perioperatively,
providing close cardiac monitoring, and allowing 20
minutes between applications to each facial subunit.
INJECTABLE SUBSTANCES
Bovine collagen dominated the U.S. market for over two
decades while the availability of filler substances in
Europe approached 100 different compounds. The early
years of the new millennium brought several new
injectables onto the U.S. market. We will classify them
into broad clinical categories of temporary and long-
acting (Box 16-2). Each injectable substance has to be
placed in an appropriate skin location to maximize
aesthetic outcome while limiting potential complications
(Fig. 16-4).
A
B
Figure 16-3 Preoperative (A) and postoperative
(B) photographs of the periorbital region of a man
who received three treatments of N-lite nonablative
laser resurfacing.

COLLAGEN
Bovine collagen was the first filler on the market, herald-
ing the modern era of noninvasive facial rejuvenation in
the 1980s. Even with the advent of longer acting fillers,
bovine- and human-derived collagen products continue to
be used extensively in the clinical setting. Collagen
products are delivered with lidocaine and therefore do not
require local anesthetic. Duration of activity for most
collagen fillers is generally 2 to 3 months. Zyderm and
Zyplast are bovine derived and require skin testing. Many
physicians will require two skin tests with 1-month and
2-week delays to decrease the rate of false negative
results. The newer generation of collagen products such as
CosmoDerm and CosmoPlast (Inamed Aesthetics, Santa
Barbara, CA) are human derived and do not require skin
testing.
Zyderm is typically injected in the superficial dermis;
Zyplast is placed in the mid-dermis using a 30-gauge
needle, which I bend to between a 90- and 150-degree
angle. One advantage of collagen over other fillers is the
absence of significant stinging and swelling. Because there
is very limited inflammation and edema, the results are
more evident at the time of injection. The post-treatment
edema is minimal and patients are able to return to work
immediately. As longer lasting fillers become more
popular, the role of collagen will likely diminish. Collagen
may continue to have a role for lip augmentation as well
as improving very fine furrows.
STABILIZED HYALURONIC ACID
There are currently several stabilized hyaluronic acid
dermal fillers on the market, including Restylane (Medicis
Aesthetics, Scottsdale, AZ), Hylaform (Inamed Aesthetics,
Santa Barbara, CA), and Captique (Inamed Aesthetics,
Santa Barbara, CA). Restylane is a cross-linked
nonanimal stabilized hyaluronic acid that had long been
available in Canada and Europe. It was first marketed in
the United States in 2003 and has achieved rapid
acceptance (Fig. 16-5). It does not require skin testing
but does induce some stinging for several minutes and
more swelling than collagen. Duration of therapeutic
effects is up to twice that of collagen in most cases (4 to
6 months). It is usually injected into the mid-dermis using
a 30-gauge needle, which I bevel up, as with collagen
injections. Restylane has a tendency to diffuse into a
wider area than Zyplast, making precision placement a
little more difficult. On the other hand, it is clear and
therefore nodularity on the lip is not as readily seen. The
aftercare for Restylane is limited to the avoidance of
extreme heat and sun for a few days. Most of the fillers are
fragile in the presence of extreme heat. Hylaform is an
animal-based hyaluronic acid which has not gained
significant following in the United States. Perlane (Medicis
Aesthetics, Scottsdale, AZ), which is longer acting than
the other hyaluronic acids, will probably replace
Restylane as the preferred filler for lip augmentation as
well as other aesthetic applications. Juvederm (Inamed
Aesthetics, Santa Barbara, CA), another cross-linked
hyaluronic acid filler, was approved by the FDA in June
2006.
266
Douglas Hamilton
Box 16-2
Temporary and Long-Acting Injectables
Temporary
Long-acting
Collagen
Trade names: Zyplast,
Zyderm, CosmoDerm,
CosmoPlast
Category: filler
Duration: 2–4 months
Allergy testing: Zyplast and
Zyderm only
Injection site: superficial/
mid-dermis
Stabilized hyaluronic acid
Trade names: Restylane,
Hylaform, Captique,
Perlane, Juvederm
Category: filler
Duration: 4–8 months
Allergy testing: no
Injection site: mid-dermis
Botulinum toxin type A
Trade name: Botox
Category: neurotoxin
paralytic agent
Duration: 3–4 months
Allergy testing: no
Injection site: muscle
Notes: only product in its
category, best choice for
crow’s-feet and dynamic
rhytids/furrows of forehead
Calcium hydroxylapatite
Trade names: Radiesse,
Radiance FN
Category: filler
Duration: 2–5 years
Allergy testing: no
Injection site: deep dermis
Notes: FDA approval for
vocal cord augmentation,
higher incidence of
nodules in lips
Polymethyl methacrylate
Trade name: Artefill
Category: filler
Duration: permanent
Allergy testing: yes
Injection site: deep dermis
Silicone
Trade names: Silikon 1000,
Adato Silol 500
Category: filler/collagen
stimulator
Duration: Permanent
Allergy testing: no
Injection site: deep dermis
Notes: FDA approved for
ophthalmic use, excellent
natural lip contour, newer
silicone oils have much
better safety profile, limited
clinical experience with
newer products
Poly-L-lactic acid
Trade names: Sculptra,
New-fill
Category: volumizer
Duration: 1–2 years
Allergy testing: no
Injection site: dermal-
subcutaneous junction
Notes: FDA approved for
HIV lipoatrophy, only
product in its class that
produces significant
volume enhancement

BOTULINUM TOXIN TYPE A
BTX-A is a polypeptide neurotoxin derived from the
anaerobic bacterium, Clostridium botulinum. Botox
(Allergan, Irvine, CA) is currently the only FDA-approved
BTX-A on the market. The mechanism of action for BTX-
A is to prevent the release of acetylcholine from the
presynaptic neuron at the neuromuscular end plate,
thereby producing temporary chemical denervation and
muscle weakness.15 BTX-A treats furrows differently than
do fillers; it reduces the muscle-induced elevations and
thereby effects a flattening of the defect. Therein, BTX-A
flattens the mountains while fillers raise the valleys.
Originally produced in the 1970s and used for several
years for strabismus and blepharospasm,16-20 its cosmetic
use began in the early 1990s for glabellar and frown
furrows.21-25 It was approved for such use in the United
States in 2002. BTX-A remains, in my opinion, the
treatment of choice among all for crow’s-feet and female
forehead furrows (Fig. 16-6). In the case of greater
muscular hypertrophy, such as the changes often seen in
males, other fillers may also be required. Lower face
rejuvenation with BTX-A has not gained significant
popularity because of the complex anatomy and higher
risks of unwanted complications. The administration of
the toxin appears disarmingly simple in the periorbital
region and in the vast majority of cases is administered
without side effects and with substantial therapeutic
benefit. It is when exceptional results occur that an
understanding of both the physiology and facial anatomy
can separate the technician from the physician.
Botox should be stored prior to and after
reconstitution at 2° to 8° C. Botox can probably be stored
up to 2 weeks after reconstitution without loss of vitality.
During the preparation phase, avoid vigorous shaking, air
bubbles, or contact with alcohol through the stopper (do
not insert needle when wet). The manufacturer recom-
CHAPTER 16
Nonsurgical Facial Rejuvenation
267
Superficial dermis
Mid dermis
Deep dermis
Dermatosubcutaneous
junction
Deep muscle
Fat
Zyderm
Zyplast, stabilized hyaluronic acid
Calcium hydroxylapatite, silicone
Poly-L-lactic acid, Polymethylmethacrylate
Botulinum toxin-A
Figure 16-4 Each injectable product needs to be placed in
an appropriate location in the skin: superficial dermis—Zyderm;
mid dermis—Zyplast, stabilized hyaluronic acid; deep dermis—
calcium hydroxylapatite, polymethyl methacrylate, silicone;
dermal-subcutaneous junction—injectable poly-L-lactic acid;
deep muscle—botulinum toxin type A
Figure 16-5 Preoperative (A) and postoperative
(B) photographs of lip augmentation in a woman
using hyaluronic acid.
A
B

mends a 2.5:1 dilution. I usually use 2:1 or 3:1 dilution.
Dilutions up to 10:1 have shown equal effectiveness, but
duration and precision of delivery may be compromised at
higher dilutions.
The clinical approach varies from physician to
physician. The typical patient is injected for horizontal
forehead lines with a total of 9 units divided equally
among three injection sites superficially along the
frontalis: midway between the frontal hairline and the
eyebrow at both midpupillary lines and center of the
forehead (Fig. 16-7). In patients whose lines are deeper or
extended further laterally, I will use 16 units divided into
a total of four injection sites with the furthest lateral being
above the midpupillary line. Sometimes I may divide the
16 units with 5 units at each of the far lateral sites and
3 units each in the two more medial sites. One may
“chase,” with 1 to 2 units either at the time of the initial
session or in 2 weeks, lines that may have been missed just
268
Douglas Hamilton
Figure 16-6 Preoperative (A) and postoperative (B) photographs of a patient with improvement of forehead rhytids after botulinum toxin type A
injection.
A
B
Figure 16-7 Botulinum toxin type A injection sites in the periorbital region. In patients with deep forehead rhytids, four injection sites (4 units per site)
are utilized halfway between the hairline and eyebrow (A). The most lateral injection is placed above the midpupillary line. For glabellar rhytids, five deep
injections are used in females. In a typical female 6 units are injected into the mid procerus just below a line joining the eyebrows. Four units are then injected
into each corrugator supercilii on a line vertically above the medial canthus and above the superior orbital rim. An additional 3 units is injected about 1 cm
above this area, and slightly laterally, thereby producing a “V” injection pattern. For the crow’s-feet, 12 units are typically injected superficially at three sites
on each side (B). It is important to stay at least 1 cm lateral to the orbital rim and above the inferior zygomatic rim in order to avoid complications.
A
B

above the eyebrows. Brow ptosis may occur if corrugators
and procerus muscle are not treated. This is usually
avoided if one stays at least 1.5 cm above the superior
orbital rim. In fact, where ptosis has occurred previously
in a patient, it is judicious to treat the frown area first and
wait 2 weeks to treat the horizontal forehead furrows.
I use 20 units to treat the glabellar area in women and,
generally, 30 units for men. The needle is directed upward
to avoid downward migration into the orbicularis oculi
with resultant lid ptosis. Five deep injections (frontalis
fibers may run superficial to the corrugators) are used in
women, and two additional 5-unit injections above the
midpupillary area (1.5 cm above the eyebrow) are used in
thick-furrowed men. In a typical woman, 6 units are
injected into the midprocerus just below a line joining the
eyebrows. Four units are then injected into each
corrugator supercilii along a vertical line above the medial
canthus and the superior orbital rim. An additional
3 units is injected 1 cm superior and lateral to this area,
producing a “V” injection pattern. In patients with flat
brows, a total of 10 additional units are injected as noted
earlier. It should be noted that this is my personal
approach; the FDA trials used seven injection sites on all
patients for the glabellar area.
For the crow’s-feet, a variable dosage is utilized,
depending upon the muscle thickness and location of
furrows; 12 units are generally injected superficially at
two or three sites on each side. It is important to stay at
least 1 cm lateral to the lateral orbital rim and above the
inferior zygomatic rim in order to avoid diplopia or lid
ptosis. For lower eyelid folds, 1 to 1.5 units can be
injected in each lower lid about 3 mm below the lid
margin along the midpupilary line. This may cause
widening of the eyes in some patients, which can be
aesthetically pleasing. Patients must have a normal snap
test in order to avoid unwanted lower lid malposition.
BTX-A treatment of perioral furrows, which usually
occur secondary to orbicularis oris hypertrophy, carries a
higher risk of complication and inconsistent results.
Perioral furrows that have not responded well to fillers
can be treated with 0.5 unit of BTX-A in each furrow up
to a maximum of 2 units for each half of the lip
(maximum of 4 units per lip). Downward turn of the oral
commissure can be treated with 2 to 3 units into the
extension of each nasolabial fold just above the ramus of
the mandible, thereby paralyzing the depressor anguli
oris. Excessive dosage and misplacement of toxin can lead
to facial asymmetry in this region because perioral
muscles have very complex and dynamic functions.
Vertical platysmal lines in the neck can be successfully
injected with up to 25 units in each vertical band (about
5 units every 1.0 cm). Two-unit injections at 1.0-cm
intervals can also be placed into the dermis of horizontal
“necklace” bands up to a total of 30 units.
Patients are advised to squint, raise their brows, or
smile for 4 hours after treatment, depending upon the
area treated, in order to facilitate movement of the toxin
into the treated muscle groups. Touching of the area is
strictly avoided, and patients with treated glabellar areas
should probably not lie down for 3 to 4 hours to avoid
ptosis. Contraindications to BTX-A are neuromuscular
disease and pregnancy; relative contraindications are
psychiatric disease with somatic manifestations, such as
hysterical conversion reactions.
POLYMETHYL METHACRYLATE
PMMA was the first permanent filler approved for
aesthetic use in the United States for treatment of
nasolabial furrows under the trade name of Artefill (Artes
Medical, San Diego, CA). PMMA microspheres are 30 to
40 μm and therefore probably are not taken up by
macrophages. Collagen skin testing is required because
Artefill consists of PMMA suspended in 3.5% bovine
collagen and 0.3% lidocaine. Experience with PMMA
began in the early 1990s in Germany.26 Outside the United
States, this product uses closed German herd hides for its
collagen source; the U.S. product utilizes American hides.
I treated the first patient in the United States
beginning FDA trials in 1998 and discovered that there is
a distinct learning curve.27 The material is injected into
the dermis at the dermal-subcutaneous junction. This
area is assessed by both visual and tactile guidelines: lack
of visible needle tip and absence of reduced resistance of
adipose tissue. Overcorrection should be avoided. Twenty
percent of the fill will be with the PMMA granules and
80% with the temporary bovine collagen. This latter 80%
is eventually replaced by the patient’s own collagen in
response to the presence of plastic PMMA microspheres.
There is a quick dissipation of Artefill bovine collagen.
After the treatment, there is a tapering of aesthetic
improvement at about 1 month with “reimprovement”
occurring over the next 2 to 3 months. At 4 months the
histology is normally stabilized.
PMMA must be reserved for expression furrows and
atrophic acne and varicella scars. The product should not
be used for the treatment of fine rhytids. Initially,
undercorrection is often achieved when the practitioner is
concerned with producing irregularities. Once a more
appropriate quantity is delivered, re-treatment incidences
approach those reported by the inventor of Artefill,
Professor Gottfried Lemperle.28 My experience with
Artefill has demonstrated excellent long-term resolution
of nasolabial folds, upper lip furrows, marionette lines,
and glabellar furrows for periods of over 5 years (Fig. 16-
8). It offers a valuable alternative to temporary fillers. As
of this writing, Artefill is still not approved for release in
the United States. It is expected that any use other than
for nasolabial folds will be considered “off label.”
Early experience with PMMA was compromised by
frequent granuloma development. This appeared to have
been related to manufacturing issues. Since 1994, the
CHAPTER 16
Nonsurgical Facial Rejuvenation
269

reported incidence of granuloma formation has been
below 0.01%. The cause of granuloma is unknown but
seems to occur after the second and third treatments.
Treating patients who have systemic infections also
appears to raise the likelihood of granulomas.
CALCIUM HYDROXYLAPATITE
CaHA (Radiesse, BioForm Medical, San Mateo, CA) is a
semipermanent filler that has enjoyed a quick surge of
popularity since it was first introduced into the U.S.
market in 2002.29-32 Radiesse, formerly known as
Radiance FN, is synthesized CaHA particles (25 to
45 μm) suspended in glycerin, water, and sodium
carboxymethylcellulose. Because CaHA occurs naturally
in bone and teeth, skin testing is not required. It is FDA
approved for vocal fold augmentation and is used as a
tissue marker because of its radiopaque characteristic.
Presently, it is being used off label for facial aesthetic
enhancement (Fig. 16-9). Published reports have been
limited with regard to its use as a facial filler, but research
in animals and its internal use suggests duration of 2 to
5 years.29-32 We have seen duration of 18 to 24 months
and counting. The material is injected into the lower
dermis and overcorrection is avoided. I prefer to have two
treatment sessions with a 1-month interval. There is a
somewhat greater tendency toward edema and bruising
with Radiesse than with other fillers. It should be used
with caution in the lips as there is a higher tendency for
nodule formation32 (I have refrained from using it here).
Because of the immediate tissue edema, there is a need for
a more rapid injection so that one does not mistake
swelling for correction. In case of overcorrection, simple
surgical extirpation appears to be more effective than
intralesional steroids because most of the augmentation is
secondary to the actual substance rather than the local
collagen response. The overall risk of granuloma
formation is very low (probably the lowest of all fillers)
with this product.
SILICONE
Injectable silicone oil has experienced a comeback in
aesthetic facial rejuvenation in the 2000s, although its use
had never fully disappeared during its banned period of
over 2 decades.33-35 Two silicone oils, Adato SIL-ol 5000
(Bausch & Lomb Surgical, Rochester, NY) and Silikon
1000 (Alcon, Fort Worth, TX), were approved in 2000 for
ophthalmic use. Silicone is polymerized dimethylsiloxane
that can take the form of solid, gel, or liquid depending on
its polymerization and cross-linkage. The highly viscous
medical-grade liquid silicone products are presently being
used off label for permanent lip augmentation and
treatment of facial furrows.
For lip augmentation, multiple microinjections
(“microdroplets”) are given along the vermilion borders
of the lips with additional two or three injections into the
mucosal aspect of the mid-upper lip. Microdroplets
consist of 0.01 mL injections separated by at least 2 to 10
mm. A total of approximately 0.1 mL is injected in each
lip. The silicone functions solely as a collagen stimulator
and not as a filler. The effects of silicone treatments are
gradual. The regional edema is gone by the next day and
patients must be apprised of the fact that the process
occurs slowly. An inflammatory process occurs with
subsequent fibrosis, creating delicate collagen strands
around each microdroplet. Although patients are almost
uniformly pleased, they must be made aware that there
are limitations as to the size that can be achieved.
The use of medical grade silicone is still controversial.
270
Douglas Hamilton
A
B
Figure 16-8 Preoperative (A) and postoperative (B) photographs of a 47-year-old woman who had long-term nasolabial fold improvement
(4 years) with polymethyl methacrylate (Artefill).

Webster reported minimal complication with the
microdroplet technique in over 500 patients using pure
medical-grade silicone.36 Others have reported local and
systemic complications such as chronic inflammation,
migration, granuloma formation, hepatitis, pulmonary
embolism, and pneumonitis.37-39 These complications are
most likely related to large-volume facial augmentation,
poor-quality silicone, and improper technique. In my
experience, silicone appears to yield the most natural lip
augmentation results of any injectable with an
extraordinarily low incidence of complications. I have,
however, observed patients from other physicians with
nodules resulting from silicone injected in the glabella,
forehead, and nasolabial folds while not finding a similar
circumstance in lip augmentation. I limit my use of
silicone to lip augmentation only.
INJECTABLE POLY-L-LACTIC ACID
PLA (Sculptra, Dermik Aesthetics, Bridgewater, NJ) is a
soft tissue filler that appears to be a valuable addition to
our armamentarium. PLA, previously known as New-fill
in Europe, is a compound that causes an inflammatory
reaction to the overlying skin.40,41 It is FDA approved for
human immunodeficiency virus (HIV) patients with facial
lipoatrophy and is currently being used as an off-label
product for aesthetic facial rejuvenation. Lipoatrophy
develops in 15% to 80% of individuals who are treated
with antiretroviral therapy that contains protease
inhibitors or nucleoside reverse transcriptase inhibitors.42
PLA is slightly different from other fillers as it provides
volume restoration to the treated area in a comparable
manner as autologous fat injections. It usually requires
three to six injections, depending on the degree of volume
CHAPTER 16
Nonsurgical Facial Rejuvenation
271
B
A
C
Figure 16-9 Long-term nasolabial fold and marionette furrow
effacement with synthesized calcium hydroxylapatite (Radiesse). Pre-
operative (A), 10-month postoperative (B), and 2-year postoperative (C)
photographs.

restoration. European studies have shown that it can last
up to 2 years but usually requires annual touch-up
injections.40,41 PLA can be used for the treatment of HIV
lipoatrophy, aesthetic facial volume restoration, and
enhancement of deep rhytids and furrows.
Sculptra is typically mixed with 3.5 mL of saline and
1.5 mL of lidocaine (without epinephrine) 6 to 24 hours
prior to the treatment. This regimen appears to have
reduced the rate of granuloma formation and needle
clumping. The injections are performed using a 25-gauge
needle after topical anesthetic is applied. PLA is typically
injected in the junction of dermis and subcutaneous fat.
Special care is made not to overcorrect the area. The
injection and immediate results are impressive as the
plane of injection is extremely fluid. Ice is applied
postoperatively, and the practitioner should aggressively
massage the treated regions. The patients are encouraged
to continue massaging the injected areas and must
understand that the immediate correction dissipates over
the ensuing 10 days. The dermal/epidermal thickening
begins about 3 weeks later and the third session typically
produces the most dramatic results. Complications
include erythema, edema, granuloma formation, and
irregularity. The product’s complication profile has
improved since its initial use in Europe. Overall, the
complication rates are reported to be lower if the product
is diluted appropriately and injected in the proper
plane.40,41 It should be understood by all physicians that
all fillers may be associated with true granulomas with
varying incidences.
Future Considerations
The future of nonsurgical facial rejuvenation will likely
focus on longer-acting fillers and creating more effective
nonablative laser technology. Several new classes of
botulinum toxins are undergoing FDA trials and will likely
increase the product line of neuromuscular paralytic
injectables. Although surgical intervention will remain an
important aspect of facial rejuvenation, nonsurgical
alternatives will continue to gain acceptance as reliable
alternatives for younger patients.
REFERENCES
1. Goldman L, Blaney DJ, Kindel J Jr, et al: Pathology of the
effect of the laser beam on the skin. Nature 1963;197:912.
2. Goldman L, Blaney DJ, Freemond A, et al: The biomedical
aspects of lasers. JAMA 1964;188(20):302.
3. Goldman L, Blaney DJ, Kindel DJ Jr, et al: Effect of the laser
beam on the skin. Preliminary report. J Invest Dermatol
1963;40:121.
4. Laub DR, Yules RB, Arras M, et al: Preliminary
histopathological observation of Q-switched ruby laser
radiation on dermal tattoo pigment in man. J Surg Res
1968;8(5):220.
5. Goldman L, Wilson RG, Hornby P, et al: Radiation from a
Q-switched ruby laser: Effect of repeated impacts of power
output of 10 megawatts on a tattoo of a man. J Invest
Dermatol 1965;44:69.
6. Dixon JA, Rotering RH, Huether SE: Patient’s evaluation of
argon laser therapy of port wine stain, decorative tattoo, and
essential telangiectasia. Lasers Surg Med 1984;4(2):181.
7. Apfelberg DB, Maser MR, Lash H, et al: The argon laser for
cutaneous lesions. JAMA 1981;245(20):2073.
8. Hamilton D: A classification of the aging face and its
relationship to remedies. J Clin Dermatol 1998;3:35.
9. Fitzpatrick RA, Goldman MP, Satur NM, et al: Pulsed carbon
dioxide laser resurfacing of photo-aged facial skin. Arch
Dermatol 1996;132(4):395.
10. Fitzpatrick TB: The validity and practicality of sun-reactive
skin types I through VI. Arch Dermatol 1988;124(6):869.
11. Glogau RG: Aesthetic and anatomic analysis of the aging skin.
Semin Cutan Med Surg 1996;15(3):134.
12. Koch RJ: Laser skin resurfacing. Facial Plast Surg Clin North
Am 2001;9(3):329.
13. Lask GL, Lee PK, Seyfadeh M, et al: Nonablative laser
treatment of facial rhytids. SPIE Proc 1997;2970:338.
14. Newman J: Nonablative laser skin tightening. Facial Plast
Surg Clin North Am 2001;9(3):343.
15. Brin MF: Botulinum toxin: Chemistry, pharmacology, toxicity,
and immunology. Muscle Nerve 1997;6(suppl):X146.
16. Scott AB: Botulinum toxin injection into extraocular muscles
as an alternative to strabismus surgery. J Pediatr Ophthalmol
Strabismus 1980;17(1):21.
17. Scott AB, Rosenbaum A, Collins CC: Pharmacologic
weakening of extraocular muscles. Invest Ophthalmol
1973;12(12):924.
18. Scott AB: Botulinum toxin injection of eye muscles to correct
strabismus. Trans Am Ophthalmol Soc 1981;79:734.
19. Scott AB: Botulinum toxin injection into extraocular muscles
as an alternative to strabismus surgery. Ophthalmology
1980;87(10):1044.
20. Clark RP, Berris CE: Botulinum toxin: A treatment for facial
asymmetry caused by facial nerve paralysis. Plast Reconstr
Surg 1989;84(2):353.
21. Blitzer A, Brin MF, Keen MS, et al: Botulinum toxin for the
treatment of hyperfunctional lines of the face. Arch
Otolaryngol Head Neck Surg 1993;119:1018.
22. Keen M, Blitzer A, Aviv J, et al: Botulinum toxin A for
hyperkinetic facial lines: Results of a double-blind, placebo-
controlled study. Plast Reconstr Surg 1994;94(1):94.
23. Carruthers A, Kiene K, Carruthers J: Botulinum A exotoxin
use in clinical dermatology. J Am Acad Dermatol 1996;
34(5 Pt 1):788.
24. Foster JA, Barnhorst D, Papay F, et al: The use of botulinum
A toxin to ameliorate facial kinetic frown lines.
Ophthalmology 1996;103(4):618.
25. Garcia A, Fulton JE Jr: Cosmetic denervation of the muscles of
facial expression with botulinum toxin. A dose-response study.
Dermatol Surg 1996;22(1):39.
26. Lemperle F, Hazan-Gauthier N, Lemperle M: PMMA
microspheres (Artecoll) for skin and soft tissue augmentation.
Part II: Clinical investigations. Plast Reconstr Surg
1995;96:627.
27. Hamilton D: A pilot study of the first patients treated in the
United States with Artecoll implantations for the aging face.
Cosmet Dermatol 2001;14(9):47.
28. Lemperle G, Hazan-Gauthier N, Lemperle M: PMMA
microspheres (Artecoll) for long-lasting corrections of
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wrinkles: Refinements and statistical results. Aesthet Plast
Surg 1998;22:356.
29. Flaharty P: Radiance. Facial Plast Surg 2004;20(2):165.
30. Skylar JA, White SM: Radiance FN: A new soft tissue filler.
Dermatol Surg 2004;30(5):764.
31. Tzikas TL: Evaluation of the Radiance FN soft tissue filler for
facial soft tissue augmentation. Arch Facial Plast Surg
2004;6(4):234.
32. Kanchwala SK, Holloway L, Bucky LP: Reliable soft tissue
augmentation: A clinical comparison of injectable soft-tissue
fillers for facial-volume augmentation. Ann Plast Surg
2005;55(1):30.
33. Benedetto AV, Lewis AT: Injecting 1000 centistoke liquid
silicone with ease and precision. Dermatol Surg
2003;29(3):211.
34. Orentreich D, Leone AS: A case of HIV-associated facial
lipoatrophy treated with 1000-cs liquid injectable silicone.
Dermatol Surg 2004;30(4 Pt 1):548.
35. Jones DH, Carruthers A, Orentreich D, et al: Highly purified
1000-cSt silicone oil for treatment of human
immunodeficiency virus-associated facial lipoatrophy: An open
pilot trial. Dermatol Surg 2004;30(10):1279.
36. Webster RC, Fuleihan NS, Gaunt JM, et al: Injectable silicone
for small augmentation: Twenty year experience in humans.
Am J Cosmet Surg 1984;1(4):1.
37. Bigata X, Ribera M, Bielsa I, et al: Adverse granulomatous
reaction after cosmetic dermal silicone injection. Dermatol
Surg 2001;27(2):198.
38. Ficarra G, Mosqueda-Taylor A, Carlos R: Silicone granuloma
of the facial tissues: A report of seven cases. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2002;94(1):65.
39. Pearl RM, Laub DR, Kaplan EN: Complications following
silicone injections for augmentation of the contours of the
face. Plast Reconstr Surg 1978;61:888.
40. Vochelle D: The use of poly-L-lactic acid in the management
of soft-tissue augmentation: A five-year experience. Semin
Cutan Med Surg 2004;23(4):223.
41. Humble G, Mest D: Soft tissue augmentation using sculptra.
Facial Plast Surg 2004;20(2):157.
42. Burgess CM, Quiroga RM: Assessment of the safety and
efficacy of poly-L-lactic acid for the treatment of HIV-
associated facial lipoatrophy. J Am Acad Dermatol
2005;52(2):233.
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273

HISTORY
Lateral canthal surgery was initially utilized for paralytic
and functional ectropion.1,2 In 1969, Tenzel3 was the first
to propose the lateral tarsal strip procedure as a method
to repair lower lid malposition. In the 1970s, the rate of
lower eyelid complications increased because of the rising
popularity of skin-muscle flap blepharoplasty.4-8 Sub-
sequently, there has been a greater understanding of post-
blepharoplasty complications as lateral canthal surgery is
now routinely utilized for both the prevention and
reconstruction of lower lid malposition.9,10
PERSONAL PHILOSOPHY
Lateral canthal surgery is an indispensable surgical tool
for surgeons interested in performing aesthetic eyelid
surgery. Lateral canthoplasty has a role in both pre-
venting and correcting post-blepharoplasty eyelid mal-
position. Furthermore, it is an essential surgical tool for
treating functional eyelid disorders such as paralytic,
involutional, and cicatricial ectropion. Surgical treatment
of the lateral canthus can allow adjustment of several
lower eyelid variables such as the angle at which the lower
lid meets the upper lid, tension on the lower lid, the
position of the lower lid relative to the corneal limbus, and
the anteroposterior position of the lower lid relative to the
upper lid (Box 17-1). Ideally, the choice of procedure that
is performed at the lateral canthus should allow the surgeon
to tailor the procedure to accommodate all these variables.
Currently, four lateral canthoplasty techniques are in
common use11: the dermal orbicular pennant, the inferior
retinacular lateral canthoplasty, the lateral retinacular
suspension, and the lateral tarsal strip. The lateral tarsal
strip is the only procedure that allows the surgeon to fully
control all the important lower eyelid variables.
In my own experience, I have chosen to use three
variations of the tarsal strip procedure to address the
lateral canthus. By varying the basic tarsal strip pro-
cedure, the surgeon has a variety of options that can be
adapted to solve a multiplicity of problems. The great
advantage of this approach is that the surgeon has full
control of the variables of lid position and tension as well
as the angulation necessary to design the appropriate lateral
canthus for a given patient. Because all these procedures
are variations of a single technique, only one learning
curve is required to master the full range of options. The
surgeon can choose the least extensive procedure that will
accomplish the desired lower lid repositioning. If the
outcome is inadequate after attempting a lesser variant,
the surgeon is still free to change to a variant that will give
a greater effect. These three variations can be performed
as isolated procedures or in combination with lower
blepharoplasty and other reconstructive techniques.
ANATOMY
The anatomy of the eyelids has been discussed at length
in Chapter 2. For the purposes of this section, the lower
eyelid anatomy is separated into three functional layers,
commonly referred to as lamellae (Fig. 17-1). The skin
and orbicularis muscle make up the anterior lamella. The
middle lamella is made up of the orbital septum, which
originates from the inferior orbital rim and inserts onto
the tarsal plate. The posterior lamella is composed of
conjunctiva and lower lid retractors. The lower lid
retractors are composed of the inferior rectus muscle as it
extends into the capsulopalpebral fascia and surrounds
the inferior oblique muscle.
The lower eyelid is suspended and supported by the
medial and lateral canthi. The lateral canthal tendon
extends from the pretarsal orbicularis oculi muscle and
tarsus to the lateral orbital tubercle approximately 2 mm
Lateral Canthoplasty
Robert E. Levine, MD
275
C H A P T E R S E V E N T E E N
Box 17-1
Lower Eyelid Variables that Can Be adjusted with
Lateral Canthal Surgery
1. The angle at which the lower lid meets the upper lid,
e.g., a sharp angle or a rounded canthal angle
2. Anterior posterior position of the lower lid relative to
the upper lid, e.g., whether they meet in the same
plane or whether the lower lid passes behind the
upper lid
3. The tension on the lower lid
4. The position of the lower lid relative to the inferior
corneal limbus in patients with lower lid retraction and
scleral show

inside the orbital rim.12 The medial canthus is usually
better suspended to the orbital rim than the lateral canthus
and therefore medial ectropion occurs less frequently. The
tarsus, canthal ligaments, and pretarsal orbicularis muscle
provide upward support for the lid whereas the skin,
orbital septum, and capsulopalpebral fascia exert an
inferior pull.
Eyelid malposition can have two distinct components:
ectropion and lid retraction. Ectropion arises when the lower
eyelid margin turns away from the globe. Lid retraction
with scleral show occurs when the eyelid is positioned
inferiorly. The anatomic causes of lower lid malposition
include vertical deficiencies in any of the three lamellae,
generalized laxity of the canthal eyelid suspension
complex, or weakness of the orbicularis oculi. Deficiency
of the anterior lamella following aesthetic surgery is
usually caused by aggressive skin and muscle resection,
which may lead to lateral canthal rounding and ectropion.
Lower lid retraction can result from middle lamellar
insufficiency secondary to contracture and scarring of the
septum. A shortened posterior lamella vertical deficiency
usually results in entropion. Box 17-2 summarizes the
issues related to post-blepharoplasty eyelid malposition.
PREOPERATIVE ASSESSMENT
Surgical manipulation of the upper eyelid is more for-
giving than that for the lower eyelid. Post-blepharoplasty
lower eyelid malposition such as ectropion and lid
retraction almost always occurs because of inadequate
preoperative evaluation. Adequate eyelid assessment will
allow the surgeon to select appropriate candidates for
lower blepharoplasty. Patients who are at risk for post-
operative eyelid malposition can then be appropriately
managed with lateral canthal surgery. Careful preoper-
ative analysis and judicious blepharoplasty techniques
with lateral canthal surgery should virtually eliminate the
long-term risk of post-blepharoplasty complications.
During the initial consultation, a complete history
and physical examination are obtained. There are two
patient populations that should be considered for lateral
canthoplasty. The first group represents patients who are
seeking surgical reconstruction for functional or post-
blepharoplasty lower lid malposition. The second group
represents aesthetic blepharoplasty patients who may
require adjunctive procedures such as lateral canthoplasty.
In the first group, the history and examination should
focus on the cause and type of functional lid malposition
in order to determine the appropriate surgical recon-
struction. Post-blepharoplasty patients with lid malposition
present with both aesthetic and functional complaints
such as eye irritation, epiphora, blurry vision, and redness.
In the second group, the surgeon should focus on key
predisposing factors for post-blepharoplasty complications
(see Box 17-2). A history of thyroid disorders, facial nerve
paralysis, prior blepharoplasty, and trauma increase the
risks of post-blepharoplasty eyelid retraction and
ectropion. Patients with thyroid-related orbital disorders
may present with scleral show, proptosis, lagophthalmos,
and pseudoherniation of orbital fat. They should first be
treated medically or by orbital decompression when
appropriate.13
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Robert E. Levine
Orbital septum
Orbicularis m.
Levator apononeurosis
Müllers m.
Tarsus
Tarsus
Capsulopalperbral
fascia
Septum
Figure 17-1 Eyelid anatomy. The lower eyelid is functionally composed
of three lamellae. The skin and orbicularis muscle make up the anterior
lamella. The middle lamella is made up of the orbital septum. The posterior
lamella is composed of conjunctiva, capsulopalpebral fascia, and lower lid
retractors.
Box 17-2
Blepharoplasty-related Eyelid Malposition
Etiology
1. Excess skin removal
2. Excess fat removal
3. Scar contracture
4. Orbicularis oculi muscle injury
5. Eyelid edema
6. Orbital septum adhesion
7. Hematoma
8. Lax lid margin
9. Proptosis
10. Unilateral high myopia
Predisposing factors
1. Involutional changes leading to hypotonicity
2. Malar hypoplasia
3. Shallow orbit
4. Graves’ disease
5. Unilateral high myopia
6. Secondary blepharoplasty
Adapted from Cheney ML: Facial Surgery: Plastic & Reconstructive.
Philadelphia: Williams & Wilkins, 1997.

The physical examination usually begins with a
thorough ophthalmologic evaluation including visual
acuity and extraocular movement testing. Lower eyelid
lash line should normally rest just above the inferior
limbus in the neutral gaze (Fig. 17-2). A small amount of
scleral show may be normal, but significant lid retraction
is aesthetically and functionally disturbing. The marginal
reflex distance-2 (MRD2) can be used to objectively
determine the significance of scleral show. MRD2 is the
distance between the corneal light reflex and the lower
eyelid lash line. which is normally about 5 mm. The
MRD2 of patients with lower lid retraction and scleral
show is usually greater than 7 mm.
The lateral canthal angle is formed by the junction of
the upper and lower eyelid adjacent to the orbital rim.
The lateral canthus in Caucasian patients should be
approximately 2 mm superior to the medial canthus
(Fig. 17-3). Lid laxity will reduce this difference. Snap
test and lid distraction tests are performed to objectively
evaluate the integrity of the lower eyelid canthal complex.
The snap test is performed by pulling the lower eyelid
down and away from the globe and asking the patient not
to blink (Fig. 17-4). The eyelid should return to its
normal resting position in less than 1 second. In the lid
distraction test, the distance that the lower eyelid can be
pulled away from the globe is measured (Fig. 17-5). A
distance of greater than 7 to 10 mm represents a lax lid.
Lateral canthal integrity can also be determined by grasp-
ing the lower eyelid and pulling it medially (Fig. 17-6).
This maneuver can usually give the surgeon an under-
standing of the degree of laxity.
The orbitofacial vector must also be determined
during the physical examination. A negative vector due to
real or apparent exophthalmos is one of the main reasons
patients develop postoperative eyelid complications.14 A
negative orbitofacial vector is diagnosed if a straight line
drawn from the cornea falls anterior to the inferior orbital
rim in the lateral view. This can result from malar
hypoplasia or myopia as well as proptosis commonly
present in Graves’ ophthalmopathy.
After the examination, a surgical treatment plan must
be established. In patients presenting for aesthetic ble-
CHAPTER 17
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277
Upper lid crease
Caruncle
Lateral canthus
Medial canthus
Lower lid crease
Figure 17-2 Marginal reflex distance-2. The Marginal reflex distance-2
(MRD2) is measured from the corneal light reflex to the lower eyelid lash
line when the patient is in a neutral gaze. The lash line should normally rest
just above the lower limbus with an MRD2 of 5 mm. In patients with lower
lid retraction and scleral show, this distance is usually greater than 7 mm.
Figure 17-3 Lower lid malposition. The lateral canthus in Caucasian
patients should be approximately 2 mm superior to the medial canthus (A).
Ectropion arises when the lower eyelid margin turns away from the globe,
and lid retraction with scleral show occurs when the eyelid is pulled
inferiorly (B).
Figure 17-4 Snap test. The lower eyelid is pulled inferiorly and away
from the globe. The eyelid should return to its normal resting position in
less than 1 second.
A
B

pharoplasty, the history and examination will determine
whether they will require simultaneous canthoplasty. In
individuals who are diagnosed with ectropion or lower lid
retraction, the type of canthoplasty must be determined.
These patients may also require adjunctive procedures to
reestablish the normal lower eyelid anatomy. Patients
with middle lamellar contraction resulting in lower lid
retraction may require spacers such as hard palate grafts15
or high-density polyethylene (Medpor, Porex Surgical
Products, Newnan, GA).16,17 Patients with severe vertical
deficiency of the anterior lamella (skin/orbicularis) may
also require midface lifting or skin grafting.18 Paralytic
ectropion may necessitate spacers or slings with tensor
fascia lata or palmaris longus.
SURGICAL TECHNIQUES
Lateral canthoplasty with or without blepharoplasty may
be performed under local anesthesia with propofol
sedation. This technique allows the surgeon to evaluate
the surgical results and level of tightening with the patient
in an upright position. Topical anesthetic in addition to
1% lidocaine with 1:100,000 epinephrine are utilized for
the local anesthesia regimen.
TYPE I LATERAL CANTHOPLASTY: MAXIMUM LID
REPOSITIONING
The first canthoplasty variant (Fig. 17-7) is similar to the
tarsal strip procedure initially described by Tenzel in
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Robert E. Levine
Figure 17-5 Lid distraction test. The lower eyelid is pulled away from
the globe and the distance is measured. A distance of greater than 7 to
10 mm represents a lax lid.
Figure 17-6 Lateral canthal integrity. The degree of lateral canthal laxity
can be determined by pulling the lower eyelid medially toward the medial
canthal tendon.
A
B
C
Figure 17-7 Type I lateral canthoplasty—maximum lid repositioning: A hemostat is used to clamp the lateral canthal angle (A). Lateral canthotomy is
performed (B). The inferior canthal tendon and the inferolateral attachments of the lid are completely released so that the lid is freely movable (C).

CHAPTER 17
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279
D
E
F
G
H
I
Figure 17-7 Continued. The lower lid is approximated to the desired position, with a slight overcorrection, and the extent of the proposed dissection
marked (D). A tarsal tongue is created by excising the excess skin-muscle and mucocutaneous junction tissues (E). An incision is made to gain access to the
upper arm of the lateral canthal tendon (F). A double-armed 4-0 Mersilene suture is sewn through the tarsus (G). Each arm is locked after undergoing a long
and short pass. The lower arm is left longer for identification. A hemostat is passed under the upper arm of the lateral canthal tendon to create a tunnel (H).
The sutures ends and tarsal tongue are brought into the tunnel (I). The ends of the suture are identified, and the superior suture placed superiorly, so as to
not twist the tarsus. The Mersilene sutures are sewn into the lateral orbital rim periosteum after the desired lid position is determined (J and K). The sutures
are always begun in the posterior periosteum so as to appose the lid well to the globe. A gray-line suture (5-0 plain gut) is placed to align the canthal angle.
It is adjusted and tied simultaneously with the Mersilene sutures under appropriate tension. The Mersilene sutures are placed above the lateral raphe.
K
J

which the lateral end of the lid is freed entirely from its
attachments, a tarsal strip is formed, and the strip is
brought underneath the upper arm of the lateral canthal
tendon. This variant is used when the maximal amount of
lid tightening, lid elevation, or upward angulation of the
canthus is required. It is also used when a canthal angle is
desired wherein the lower lid passes behind the upper lid.
It is important to keep in mind that if the lower lid is
pulled too tightly over a prominent globe, the result will
create a short chord that actually passes below the globe.
In such instances, it is preferable to use a combination of
other procedures together with the lateral canthoplasty,
such as medial canthoplasty, fascia lata or palmaris
longus suspension of the lid, or placement of a central
stent to elevate the lid.
The maximal lid repositioning procedure begins with
the clamping of the lateral canthal angle with a hemostat
in order to improve surgical hemostasis. The clamp is
removed and a lateral canthotomy performed. The
inferior canthal tendon and the inferolateral attachments
of the lid are completely released in order to allow the lid
to freely move. The lower lid is approximated to the
desired position, with a slight overcorrection, and the
extent of the proposed dissection marked. Excess skin-
muscle and mucocutaneous junction tissues are excised,
leaving a tarsal tongue.
An incision is then made to gain access to the upper
arm of the lateral canthal tendon. The lateral extension of
an upper lid blepharoplasty incision may be utilized for
this access. A double-armed 4-0 Mersilene suture is sewn
through the tarsus. Each arm undergoes a long pass
followed by a short pass, and each arm is locked. The
lower arm is left longer for identification. A tunnel is
created by passing a hemostat under the upper arm of the
lateral canthal tendon. The suture ends and tarsal tongue
are brought under the tunnel and identified. The superior
suture is placed superiorly in order not to twist the tarsus.
A gray-line suture of 5-0 plain gut is placed to align the
canthal angle. It is adjusted and tied simultaneous with
the Mersilene sutures.
The Mersilene sutures are passed into the lateral
orbital rim periosteum after determining the desired lid
position. The sutures are always begun in the posterior
periosteum, so as to appose the lid well to the globe.
Sutures are tied under appropriate tension which can
usually be ideally determined with the patient in the
seated position on the operating table. Note that in this
procedure, the sutures are placed above the lateral raphe.
TYPE II LATERAL CANTHOPLASTY: MODERATE
LID TIGHTENING
The second canthoplasty variant differs from the type I
canthoplasty; whereas the lid is still freed from the
inferior arm of the lateral canthal tendon, it is not as
completely released from its inferolateral attachments.
The lower lid is therefore just free enough to be
repositioned to the desired location. Additionally, instead
of bringing the tarsal strip through a tunnel, it is sutured
directly to the inner aspect orbital rim periosteum (Fig.
17-8). This variant is utilized when there is a moderate
amount of lid laxity or preexisting eyelid malposition.
280
Robert E. Levine
A
B
C
Figure 17-8 Type II lateral canthoplasty—moderate lid tightening. A hemostat is used to clamp the lateral canthal angle, and a lateral canthotomy is
performed (A). Appearance of the lid after canthotomy (B). The inferior canthal tendon is cut, but the inferolateral attachments of the lid are only minimally
released so that the lid is movable just enough for tightening (C).

The procedure is started by clamping the lateral
canthal angle with a hemostat. Lateral canthotomy is
then performed. The inferior canthal tendon is cut, but
the inferolateral attachments of the lid are only minimally
disturbed, allowing the lid to be mobile enough for
tightening. The lower lid is approximated to the desired
position, with a slight overcorrection, and the extent of the
proposed dissection marked. Excess skin-muscle and
mucocutaneous junction tissue are excised, leaving a
tarsal strip. A double-armed 4-0 Mersilene suture is sewn
through the tarsus undergoing a long pass followed by a
short pass. The lower arm is left longer for identification.
No tunnels are made, in contrast to the type I can-
thoplasty. The suture ends are passed directly onto the
inner aspect of the orbital rim periosteum. The superior
suture is placed superiorly in order not to twist the tarsus.
A gray-line suture of 5-0 plain gut is placed to align the
canthal angle. It is adjusted and tied simultaneous with
the Mersilene sutures. Sutures are tied under appropriate
tension with the patient in a seated position on the
operating table. Note that in this procedure, the sutures
are placed at or below the lateral raphe.
TYPE III LATERAL CANTHOPLASTY: MINIMAL LID
TIGHTENING
The third canthoplasty variation is utilized when only a
minimal amount of lid tightening or elevation is required.
This canthopexy procedure is accomplished by plicating
the inferior arm of the lateral canthal tendon to the orbital
rim periosteum without dissecting the lid free of its
attachments (Fig. 17-9). Unlike the first two variations,
the canthal angle is not opened. The procedure is per-
formed by an internal approach, and access to the inferior
arm of the lateral canthal tendon is gained through an
incision at the lateral raphe. This may be the lateral
CHAPTER 17
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281
D
E
F
G
H
Figure 17-8 Continued. The lower lid is approximated to the desired position, with a slight overcorrection, and the extent of the proposed dissection is
marked (D). Excess skin-muscle and mucocutaneous junction tissue are excised, leaving a tarsal tongue (E). A double-armed 4-0 Mersilene suture is sewn
through tarsus (F). Each arm is locked after undergoing a long and short pass. The lower arm is left longer for identification. The sutures ends are passed
directly into the orbital rim periosteum (G). No tunnels are made and the ends of the sutures are identified in order to place the superior suture cephalad so
as to not twist the tarsus. The sutures are begun in the posterior periosteum in order to appose the lid and the globe. The sutures are placed at or below
the lateral raphe. A gray-line suture of 5-0 plain gut is placed to align the canthal angle. It is adjusted and tied simultaneous with the Mersilene sutures (H).

282
Robert E. Levine
A
B
C
D
Figure 17-9 Type III lateral canthoplasty—minimal lid tightening. The canthal angle is not opened (A). Access to the inferior arm of the lateral canthal
tendon is gained through an incision at the lateral raphe. This may be the lateral extension of a lower lid blepharoplasty incision. A tunnel is made with the
scissors to the inferior arm of the lateral canthal tendon (B). The tendon is not cut. The medial end of the tendon is grasped with forceps and pulled out of
the tunnel (C). A double-armed 4-0 Mersilene suture is sewn through the tendon (D). The lower arm is left longer for identification. The Mersilene sutures
are passed into the lateral orbital rim periosteum (E). The sutures are always begun in posterior periosteum, so as to appose the lid well to the globe. Sutures
are tied under appropriate tension.
E

extension of a lower lid blepharoplasty incision. A tunnel
is made with the scissors to the inferior arm of the lateral
canthal tendon. The medial end of the tendon is grasped
with forceps and pulled out of the tunnel without cutting
any attachments. A double-armed 4-0 Mersilene suture is
sewn through the tendon with the lower arm left longer
for identification. The Mersilene sutures are passed into
the lateral orbital rim periosteum. As in the other
variations, the sutures are always begun in the posterior
periosteum so as to oppose the lid well to the globe.
Sutures are then tied under appropriate tension with the
patient in the seated position on the operating table. As
with type II canthoplasty, the sutures are placed at or
below the lateral raphe.
POSTOPERATIVE CARE
The patients are usually prescribed analgesics and
antibiotics after the procedures. Ophthalmic antibiotic
ointments are used on the incision line to keep the wound
moist and clean. The patients are encouraged to use cold
compresses in the first 2 to 3 postoperative days and asked
to switch to warm compresses thereafter. The patients are
seen on postoperative days 3 and 7 for examination and
suture removal. The degree of postoperative edema is
dependent on the extent of surgical manipulation.
COMPLICATIONS
The most common complication associated with lateral
canthoplasty involves persistent or iatrogenic eyelid mal-
position requiring additional reconstructive procedures.
These patients not only require revision canthoplasty but
may also need adjunctive procedures such as middle
lamellar stents, endoscopic midface lifts, fascia lata slings,
or skin grafting. Other complications of canthal surgery
include asymmetry, infection, corneal abrasion, and
bleeding. As with all eyelid procedures, retrobulbar
hematoma leading to vision loss is an extremely rare
complication.
Future Considerations
The future of eyelid reconstruction will continue to
converge on improving preoperative evaluation as well
as increasing the patient and physician awareness of post-
blepharoplasty eyelid malposition. The continued trend
for utilizing the transconjunctival technique for lower
blepharoplasty as well as preventive canthoplasty will
result in fewer post-blepharoplasty complications.
REFERENCES
1. Converse JM, Smith B: Canthoplasty and
dacrocystorhinostomy. Am J Ophthalmol 1952;35(8):1103.
2. Beard C: Canthoplasty and brow elevation for facial palsy.
Arch Ophthalmol 1964;71:386.
3. Tenzel RR: Treatment of lagophthalmos of the lower eyelid.
Arch Ophthalmol 1969;81:366.
4. Edgerton MT Jr: Causes and prevention of lower lid ectropion
following blepharoplasty. Plast Reconstr Surg 1972;49(4):367.
5. Rees TD: Correction of ectropion resulting from
blepharoplasty. Plast Reconstr Surg 1972;50(1):1.
6. Levine MR, Boynton J, Tenzel RR, et al: Complications of
blepharoplasty. Ophthalm Surg 1975;6(2):53.
7. Tenzel RR: Surgical treatment of complications of cosmetic
blepharoplasty. Clin Plast Surg 1978;5(4):517.
8. Friedman WH: Ectropion after blepharoplasty. Experimental
and clinical observations. Arch Otolaryngol 1979;105(8):455.
9. Nowitzki T, Anderson RL: Advances in eyelid malposition.
Ophthalmol Plast Reconstr Surg 1985;1:145.
10. Carraway JH, Mellow CG: The prevention and treatment of
lower lid ectropion following blepharoplasty. Plast Reconstr
Surg 1990;85(6):971.
11. Shorr N, Goldberg R, Eshagian B, Cook T: Lateral
canthoplasty. Ophthal Plast Reconstr Surg 2003;19(5):345.
12. Dutton J: Clinical and surgical orbital anatomy. Philadelphia:
WB Saunders, 1994, p 123.
13. Leone CR Jr: The management of ophthalmic Graves’ disease.
Ophthalmology 1984;91(7):770.
14. Shorr N, Enzer Y: Considerations in aesthetic eyelid surgery.
J Dermatol Surg Oncol 1992;18:1081.
15. Shorr N: Madame butterfly procedure with hard palate graft:
Management of post-blepharoplasty round eye and scleral
show. Facial Plast Surg 1994;10(1):90.
16. Tan J, Olver J, Wright M, et al: The use of porous polyethylene
(Medpor) lower eyelid spacers in lid heightening and
stabilisation. Br J Ophthalmol 2004;88(9):1197.
17. Morton AD, Nelson C, Ikada Y, et al: Porous polyethylene as a
spacer graft in the treatment of lower eyelid retraction.
Ophthal Plast Reconstr Surg 2000;16(2):146.
18. Patel MP, Shapiro MD, Spinelli HM: Combined hard palate
spacer graft, midface suspension, and lateral canthoplasty for
lower eyelid retraction: a tripartite approach. Plast Reconstr
Surg 2005;115(7):2105-2114; discussion 2115.
CHAPTER 17
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283

HISTORY
Aesthetic and reconstructive rhinoplasty is commonly
acknowledged as the most demanding and difficult of the
plastic surgical procedures. Although many technical
advances have occurred throughout the past century, its
fundamental philosophy remains constant. This philos-
ophy involves significant planning and conservative
surgical changes to achieve a natural-appearing result.
Initially, the operation generally involved a tissue reduction
procedure with excision of various nasal anatomic
components. More recently, rhinoplasty has evolved into
a procedure that involves tissue reorientation and aug-
mentation, with careful attention to long-term surgical
outcome.
PERSONAL PHILOSOPHY
Rhinoplasty is a complex operation that requires precise
preoperative diagnosis to select the appropriate surgical
technique. Owing to variations in nasal anatomy and
aesthetic expectations, no single technique is appropriate
for all patients. Each rhinoplasty patient presents the
surgeon with a diversity of nasal anatomy, contours, and
proportions that require a series of organized maneuvers
tailored to the patient’s anatomic and functional needs.
The surgeon must also be skilled at manipulating and
controlling the dynamics of postoperative healing to
attain optimal long-term aesthetic results. A necessary
prerequisite is the skill to visualize the ultimate long-term
healed result while manipulating the nasal structures.
ANATOMY
Aging of the nasal structures and external contour of the
nose is influenced by a variety of genetic and environ-
mental factors. Additionally, the nasal shape changes over
time as well. In children, the nasal dorsum is typically
concave, and assumes a more straight or convex shape in
early adult life. This convexity is further enhanced in
midlife by the development of a drooping, ptotic tip. In
addition to these changes to the appearance of the nose,
nasal function tends to deteriorate over time as the nasal
airway changes.
As patients age, the skin thins with loss of elasticity,
subcutaneous fat deposits resorb, and the underlying soft
tissues atrophy. With these changes, the underlying
support structures of the nose, such as the lower lateral
cartilages and nasal bones, become skeletonized or visible.
In addition, skin hydration is diminished, and the skin
becomes less pliable.1 This affects the skin’s ability to
contract and redrape after the cartilaginous and bony
structures of the nose are reduced.
The most significant changes over time occur in the
upper and lower lateral cartilages. These cartilages are
connected by a fibrous union at the cephalic margin of the
lateral crura, the scroll region.1 As the nose ages, the
upper and lower lateral cartilages begin to separate and
fragment.2,3 This may result in collapse of the internal
nasal valve and lateral wall. As one ages, the middle nasal
vault will tend to collapse as the upper lateral cartilages
move inferomedially. Loss of support of the medial crura
and stretching of the fibrous attachments from the
posterior septal angle and nasal spine to the medial crural
footplates result in their posterior movement and
retraction of the columella.3 These changes also occur by
loss of the fat pad below the medial crura and resorption
of the premaxilla.2 With loss of support of the medial
crura and separation of the lateral crura from the upper
lateral cartilages, the nasal tip may become ptotic, with
an appearance of increased length and a more acute
nasolabial angle.
With aging, the nasal bones may become brittle and
are more readily fractured.4 Care must be taken during
osteotomies to avoid excessive narrowing of the bony vault
or comminuted fractures of the nasal bones. Periosteal
elevation is not recommended in the aging patient and if
used should not extend to the point of the intended lateral
osteotomies, to avoid loss of periosteal support.4 Although
undesirable in the younger patient, greenstick fractures
can be effective in the older patient.4 Finally, dorsal hump
reduction must be executed with great precision to
minimize irregularities of the bony nasal vault as the skin
over the dorsum tends to be very thin.
Rhinoplasty in the Aging Patient
Ryan M. Greene, MD, PhD • Dean M. Toriumi, MD
285
C H A P T E R E I G H T E E N

PREOPERATIVE ASSESSMENT
Preoperative assessment of the rhinoplasty patient includes
not only the assessment of the anatomic and functional
components, but also the emotional and psychological
factors.5 As with all facial aesthetic surgery, it is
important for the physician to discuss motivation and
aesthetic goals of rhinoplasty surgery with the patient. It
is critical to elucidate what aesthetic changes the patient
desires. Older patients have developed a self-image over
many years, and must be prepared for the planned surgical
changes. Many older patients do not want to look
dramatically different, and thus conservative changes are
generally most appropriate. Patients who desire dramatic
changes warrant careful evaluation prior to consideration
as surgical candidates.
In this age group, a thorough preoperative medical
examination is mandatory. Many of these patients have
co-morbid medical conditions. A careful medical history
and physical examination are critical prior to performing
this type of surgery. It is often a good idea to consult with
the patient’s primary care physician prior to scheduling
surgery. Many of these patients take medications that can
affect clotting. These medications should be stopped at
least 2 weeks before surgery.
SURGICAL TECHNIQUE
PREOPERATIVE CONSIDERATIONS
The surgical approaches to the nose include nondelivery
techniques (cartilage-splitting or retrograde approach),
delivery of bilateral chondrocutaneous flaps, and the
external rhinoplasty approach. Selection of the approach
should be based on both operative objectives and surgical
experience. When only conservative volume reduction of
the lateral crura and dorsal hump reduction are planned,
a nondelivery approach (cartilage-splitting or retrograde
approach) will suffice. However, when more complex nasal
tip work is required, delivery of bilateral chondro-
cutaneous flaps or the external rhinoplasty approach
should be used. The external approach is preferred when
complex tip grafting or middle nasal vault reconstruction
is planned. Regardless, the surgeon should select the least
invasive approach possible to avoid disruption of nasal
support mechanisms and maximize the functional and
aesthetic result.
External incisions can be used with greater frequency
in older patients because the skin is less likely to scar
unfavorably.6 Nasal skin in the aging patient also has
multiple rhytids that can aid in camouflage. Even though
it is rarely necessary, direct excision of skin from the nasal
dorsum or supratip can be performed to aid redraping of
the skin or elevating the severely ptotic nasal tip.7-9
Because of the thin skin found in the aging nose, even the
smallest irregularities or asymmetries can become notice-
able. As a result, debulking of underlying subcutaneous
fat and muscle tissue should not be performed. This
subcutaneous tissue should be preserved to maximize
camouflage of the cartilage and bone. Tip grafts should
also be limited unless the patient has medium to thick
skin.10 If they are used, they should be carefully sculpted
and camouflaged to avoid visible edges. With thin skin, a
thin layer of perichondrium or superficial temporal fascia
can be applied over the graft, with an understanding that
it will create temporary edema of the grafted area that
should resolve over 6 to 12 months.
When treating the aging nose, the nasal tip should be
managed first to set tip projection and rotation before
completing profile alignment. After setting appropriate
tip projection, dorsal hump reduction may not be needed.
Frequently, older patients will also benefit from augmen-
tation of the radix to create a straight profile. This
strategy of increasing tip projection and raising the radix
allows the surgeon to preserve a high dorsal profile while
also creating a favorable tip-supratip relationship (Fig.
18-1). As mentioned earlier, only conservative changes
should be made in the nasal contour because older
patients tend to have a set self-image. The nose should
also be in harmony with the patient’s other facial features.
THE EXTERNAL APPROACH
The patient is first injected with 1% lidocaine with
1:100,000 epinephrine into the nasal tip, between and
around the domes, down the columella, along the site of
the marginal incision, and along the lateral wall of the
nose. Additional injections high on the nasal septum and
along the osteotomy sites are then placed. An inverted-V
columellar incision is then marked, midway between the
base of the nose and the top of the nostrils. A transcol-
umellar incision is executed with a No. 11 blade. Care
must be taken to avoid damaging the caudal margin of
the medial crura. Marginal incisions are then made along
the caudal margin of the lateral crura, which are extended
to meet the columellar incision.
After completing the incisions, angled Converse
scissors are used to elevate the skin off the medial crura.
Once the columellar flap is elevated off the medial crura,
dissection is advanced laterally to expose the lateral crura.
A thin layer of perichondrium is left on the surface of the
lower lateral cartilages. The anterior septal angle is
identified, with exposure of the middle nasal vault in the
midline. Blunt dissection is continued to the rhinion,
which may be followed by subperiosteal dissection of the
skin off the nasal dorsum up to the nasion if profile
alignment is necessary. If a radix graft is planned, then a
narrow pocket should be dissected in the midline over the
radix. This narrow pocket will prevent shifting of a radix
graft if radix augmentation is necessary.
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Ryan M. Greene • Dean M. Toriumi

SEPTAL SURGERY
When performing septal surgery in the older patient,
dissection of the mucosal flaps should be limited because
the mucoperichondrium is thinner and drier. A sub-
stantial L-shaped septal strut should be preserved in
order to support the lower two thirds of the nose. We
prefer to leave at least a 2-cm anterior septal strut and
1.5-cm caudal strut for support. Extra cartilage should be
left at the osseocartilaginous junction to avoid loss of
dorsal septal support. A Killian incision is preferred
because of its excellent exposure without compromise of
the support attachments between the feet of the medial
crura and the caudal septum. A hemitransfixion incision
can be used if exposure of both sides of the caudal nasal
septum is required. The hemitransfixion or full trans-
fixion incision can sometimes lead to a loss of support due
to disruption of some of the attachments between the
medial crura and caudal septum. When a decrease in tip
projection is desired, a full transfixion incision can be
used to disrupt these attachments.
When exposing the septal cartilage in the aging patient,
it is generally preferable to raise a mucoperichondrial flap
on only one side of the septum, in order to preserve the
vascular supply of the contralateral side and minimize
chances of hematoma formation. After completion of the
septal surgery, a running 4-0 plain catgut mattress suture
is used to approximate the mucoperichondrial flaps and
prevent fluid collection and hematoma formation. By
limiting septal surgery, nasal packing can be minimized or
avoided. The surgeon should be aware that the septal
cartilage may be partially calcified, which leaves the
surgeon with less cartilage for harvesting or grafting.
In some patients it may be necessary to dissect
between the medial crura to access the caudal septum.
Patients with a deviated caudal septum may benefit from
this approach to allow correction of the deformity. Other
patients with poor tip support could benefit from
stabilization of the nasal base through this approach.
PTOTIC NASAL TIP
As the nose ages, the nasal tip frequently droops, creating
a ptotic nasal tip. This change in nasal contour gives an
elongated appearance. Patients that have shorter medial
crura are more likely to develop tip ptosis due to lack of
support. Patients with long medial crura that wrap
around the nasal spine and caudal septum are less likely
to develop tip ptosis (Fig. 18-2). Severe ptosis of the nasal
tip can also result in nasal airway compromise by altering
the pathway of inspiratory air currents.3 Correction of the
ptotic nasal tip generally involves increasing nasal tip
rotation and projection. As demonstrated by the tripod
concept described by Anderson,11 ptosis of the nasal tip
can usually be corrected by supporting the medial and
intermediate crura or by shortening the lateral crura.
We typically use a graduated approach for correction
of the ptotic nasal tip by initially considering placing a
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A
B
C
Figure 18-1 Part A shows a profile of an aging patient. Note the underprojection of the nasal tip. Placement of a caudal extension graft with septal
cartilage overlapping the existing nasal dorsum is shown in B. Note the increased tip projection to create a straight dorsal profile in part C.

sutured-in-place columellar strut between the medial
crura. We have found this to be particularly effective if the
dependent lobule is caused by buckling of the medial or
intermediate crura. A sutured-in-place columellar strut
both provides support and straightens buckled medial
and intermediate crura. A straight rectangular piece of
septal cartilage is placed in a precise pocket created
between the medial and intermediate crura.10 The col-
umellar strut is fixed into position using a 5-0 plain catgut
suture on a straight septal needle. The strut is easily applied
using the external rhinoplasty approach, which allows
maximal visualization, precise placement, and suture
fixation of the graft. These struts can also be applied
using a small endonasal incision placed just caudal to the
caudal margin of the medial crura. Once the incision is
made, a precise pocket is made between the medial crura
for graft placement and suture fixation.
In many patients, a columellar strut will not provide
sufficient support to the nasal base. These patients will
require more significant structural support. One option is
to suture the medial crura to the caudal septum. This
maneuver will shorten the nose and support the nasal
base. This technique should be used only when the caudal
septum is long and would otherwise require shortening.
Another option is to use a caudal extension graft. Such a
graft is typically overlapped and sutured to the existing
caudal septum. Then the medial crura are sutured to the
caudal margin of the caudal extension graft to stabilize
the nasal base and reposition the nasal tip. The caudal
extension graft must be in the midline and oriented to
increase tip rotation. Fixation of the medial crura to the
caudal septum or an extension graft provides increased tip
support (Fig. 18-3). Such fixation creates moderate
rigidity of the nasal tip that can be discussed with the
patient preoperatively.
If stabilizing the nasal base does not adequately cor-
rect the ptotic nasal tip, then additional surgical maneuvers
must be used to increase tip rotation. The objective of
these maneuvers is to rotate the nasal tip by recruiting
lateral crura medially. Placement of a transdomal suture
recruits lateral crura medially to increase tip projection
and rotation.12,13 Without violating the underlying
vestibular skin, a 5-0 clear nylon suture is placed in a
horizontal mattress fashion across both domes. To recruit
the lateral crura medially, the lateral bite of the suture
extends lateral to the anatomic dome. This suture narrows
the nasal tip by approximating the domes and creating a
more acute domal angle, in addition to increasing tip
projection and rotation. In some cases, the transdomal
suture can further compromise the nasal airway if the
lateral crura protrude into the airway. Such obstruction
can be avoided by using an alar batten graft or lateral
crural strut graft to lateralize the offending lateral
segment of the lateral crus. If the transdomal suture does
not correct the ptotic nasal tip, it may be necessary to
perform a more aggressive maneuver that shortens the
lateral crura.
The lateral crural overlay technique is a procedure
that increases tip rotation by shortening the lateral crura.
In this technique, the lateral crura are incised at the
midpoint, and the medial segment is dissected from the
underlying vestibular skin (Fig. 18-4). The cut ends of
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Ryan M. Greene • Dean M. Toriumi
A
B
C
Figure 18-2 Relationship between medial crura and footplates to the caudal septum. Long strong medial crura extend to base of nose near posterior
septal angle and wrap around caudal septum (A). This relationship provides excellent nasal tip support. Short medial crura do not extend to the nasal base
and provide less tip support (B). Short caudal septum with separation of medial crura away from caudal septum results in loss of tip support (C).

cartilage are then overlapped (3 mm or 4 mm) and
resutured with two 5-0 clear nylon mattress sutures to
reconstitute the lateral crural segments into their
shortened configuration. The degree of tip rotation is
directly proportional to the degree of overlap (shortening)
of the lateral crura. Symmetric alignment of the lateral
crura must be achieved to avoid tip or alar margin asym-
metry (Fig. 18-5).
Another technique employed in tip control involving
the lower lateral cartilages is the lateral crural wedge
technique (Fig. 18-6). The wedge resection of the lower
laterals is made to rotate the tip cephalad. In most cases,
adequate correction of the ptotic nasal tip requires the use
of more than one of the aforementioned techniques. An
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289
effective combination for correction of the ptotic tip is a
lateral crural overlay with a caudal extension graft.
Once the ptosis of the nasal tip has been corrected,
additional tip projection can be achieved by suturing a
shield-shaped cartilage tip graft into position. A tip graft
is sculpted from septal cartilage and sutured to the caudal
margin of the medial and intermediate crura with 6-0
PDS (polydioxanone) suture (Ethicon, Somerville, NJ).
The tip graft serves to provide additional tip projection,
hide tip asymmetries, improve the shape of the lobule,
and increase tip support.14 The use of tip grafts should be
limited in older patients, because maximal tip refinement
is generally unnecessary. In addition, the leading edge of
the tip graft will be more visible beneath the thinner skin
A
B
C
D
Figure 18-3 Caudal extension graft. The caudal extension graft is shown intraoperatively in part A. The graft then is shown sutured into place (B). Note
the harvesting site, maintaining the L-shaped support. The caudal view of the graft sutured into position is shown in C. The superior view of the graft sutured
into position is shown in D. Note how the caudal extension graft typically overlaps the existing caudal septum. It is critical that the caudal margin of the
extension graft is in the midline.

290
Ryan M. Greene • Dean M. Toriumi
A
B
C
D
E
F
Figure 18-4 Lateral crural overlay technique. The overly
long lower lateral cartilages are illustrated in A. The overly
long lateral crura are seen intraoperatively in B. The cartilages
are marked for excision in C and D. Lateral crura overlap is
depicted in E. An intraoperative photo of cartilage dissected
from underlying vestibular skin is shown in F.

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291
G
H
I
K
J
Figure 18-4 Continued. Lateral crura ends are resutured in G and H. Excessive caudal margins
of the overlapped cartilage are trimmed in I. Lateral crura are realigned, symmetrical, and stable in
J and K.

of these patients and should be limited to patients with
thicker skin. In thin-skinned patients, the leading edge of
the tip graft should be camouflaged with crushed cartilage
or soft tissue (perichondrium, fascia, etc.) (Fig. 18-7).
Other nasal tip problems, such as an underprojected
or bulbous tip, can be managed by other techniques
commonly used in younger patients. However, care must
be taken to preserve as much of the cartilaginous
framework as possible. Emphasis should be placed on
repositioning existing cartilage structures, rather than
excising them. The weaker cartilages of the aging nose are
also more prone to deformity (e.g., buckling, bossae)
under the forces of scar contracture. When performing
volume reduction of the lateral crura in the aging patient,
resection should be primarily medial, leaving at least 8 to
10 mm of intact strip.
It is imperative that the surgeon anticipates the
effects of scar contracture on the reduced cartilages. It is
shortsighted to try to attain the ideal final result at the
time of surgery, which neglects the additional refinement
that occurs with resolution of edema and healing.
Therefore, the surgeon can anticipate additional tip
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Ryan M. Greene • Dean M. Toriumi
A
B
C
D
Figure 18-5 Patient with ptotic nasal tip. The
lateral crural overlay technique was used to shorten
the lateral crura and rotate the nasal tip. Pre-
operative (A, C, E, and G) and postoperative (B, D,
F, and H) views.

refinement that will result from postoperative forces of
scar contracture. Finally, aesthetic changes should be
conservative because older patients are more set in their
self-image, as well as their perception of acceptable change
in nasal contour.
NARROWED MIDDLE NASAL VAULT
In some older patients, an excessively narrow middle
nasal vault can result when weak upper lateral cartilages
collapse inferomedially. Severe collapse may also result in
collapse of the internal nasal valve. These patients
experience improvement in their nasal airway obstruction
while performing the “Cottle maneuver” or with
lateralization of the lateral nasal wall with an instrument.
To correct this deformity, the surgeon can apply bilateral
spreader grafts between the dorsal (anterior) margin of
the nasal septum and the upper lateral cartilages.14-16
These grafts are rectangular in shape and measure
approximately 5 to 15 mm in length, 3 to 5 mm in width,
and 1 to 2 mm in thickness. The majority of spreader
grafts extend from a point just cephalic to the anterior
septal angle to the osseocartilaginous junction. In most
older patients with a functional deficit at the internal
nasal valve or lateral wall, spreader grafts will be insuf-
ficient, and alar batten grafts should be used. These
cartilage grafts are placed caudal to the existing lateral
crura to support the lateral wall.
Spreader grafts can be applied via an endonasal
approach into precise submucosal tunnels16 or may be
applied directly between the upper lateral cartilages and
the nasal septum via the external rhinoplasty approach.6,15
In the external rhinoplasty approach, the upper lateral
cartilages are freed from the nasal septum after the
middle nasal vault is exposed. The rectangular spreader
grafts are then applied between the upper lateral
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293
E
F
G
H
Figure 18-5 Continued.

cartilages and septum, and sutured into place with a 5-0
PDS mattress suture. With incorporation of the upper
lateral cartilages in the suture, the middle nasal vault
width is set and inferomedial collapse of the upper lateral
cartilages is avoided. Patients with short nasal bones are
at higher risk of collapse and will need thicker and longer
spreader grafts. Careful attention must be given to the
width of the middle nasal vault to avoid creating excessive
width with the spreader grafts. If possible, the surgeon
should try to avoid dividing the upper lateral cartilages
from the septum, in order to preserve support in the older
patient. Thus, if dorsal hump reduction is not needed, the
spreader grafts may be placed into submucosal tunnels
made via a small intranasal incision, with preservation of
the attachment of the upper lateral cartilages to the
septum.6,16
PROFILE ALIGNMENT AND NARROWING THE
NOSE
Successful management of the bony nasal vault involves
conservative dorsal hump reduction, preservation of a
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Ryan M. Greene • Dean M. Toriumi
A
B
C
D
Figure 18-6 Lateral crural wedge technique. Overly long lateral
crura contribute to the ptotic nasal tip (A). The planned wedge is
outlined on the lateral crura (B). The lateral crura wedge is excised
(C). Lateral crura are resutured, thus rotating the tip cephalad (D).

high dorsal profile, and avoidance of dorsal irregularities.
Because the nasal bones in the aging patient can be thin
and brittle, careful manipulation of the bony vault must
be exercised in order to avoid comminuted fractures or
excessive narrowing of the bony vault. Typically, con-
servative dorsal hump reduction is performed after tip
position is set. In patients with a deep nasofrontal angle,
small crushed-cartilage radix grafts can be placed above
a dorsal hump to create a straight profile (Fig. 18-8). In
many cases, dorsal hump reduction can be avoided if the
profile can be corrected with the use of a radix graft in
combination with an increase in tip projection and
rotation. The surgeon should consider a radix graft in
patients who demonstrate a deep nasofrontal angle with a
low nasal starting point. The nasal starting point should be
located at the level of the superior palpebral fold in female
patients, with a slightly higher location in male patients.
For larger dorsal hump reductions, a Rubin osteotome
can be used, while smaller dorsal humps can be managed
with a fine rasp. With larger dorsal humps, wide under-
mining of the overlying skin-soft tissue envelope is
necessary to accommodate for reduced skin elasticity and
less rapid shrinkage and redraping. Because the thin skin
of older patients shows even the smallest dorsal
irregularity, special care must be taken to ensure a smooth
dorsum. Following profile alignment, lateral osteotomies
can be performed using the smallest osteotome possible to
minimize trauma and bleeding. Often a 2- or 3-mm
straight osteotome can be used to fracture the thin
bone.6,16 In most aging patients, medial osteotomies can
be avoided as the bones are readily fractured.
EXTERNAL NASAL VALVE COLLAPSE
Older patients often present to the surgeon with
complaints of nasal airway obstruction located primarily
at the entrance to the nose (nostril margin). The nostrils
may collapse on moderate to deep inspiration, with
inadequate support of the lateral nasal wall and alae
secondary to weak lower lateral cartilages. In some cases,
the lateral crura are in a cephalic position and provide
little support to the alar side walls.15,17,18 This deficiency
has been described as “external nasal valve collapse” and
can be diagnosed by observing alar collapse on deep
inspiration. These patients will characteristically expe-
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295
A
C
B
Figure 18-7 A and B show a tip graft camouflaged with a crushed
cartilage graft behind the leading edge of the tip graft. C shows a tip graft
from the anterior view sutured in position.

rience improved nasal airflow if the alae are supported
during nasal breathing.
Internal or external nasal valve collapse can be
surgically corrected by applying bilateral alar batten
grafts at the site of maximal lateral nasal wall collapse or
near the nostril margin, respectively.15,17,18 Alar batten
grafts can be fashioned from curved cartilage of the nasal
septum or of the cavum or cymba conchae of the ear. The
concave surface of the batten graft is oriented medially to
support the collapsing segment of the nostril (external valve
collapse) or lateral nasal wall (internal valve collapse). To
correct external valve collapse, the grafts are typically
placed just caudal to the lateral crura and extend from the
pyriform aperture to the lateral aspect of the lateral crura
(Fig. 18-9). For internal valve collapse, the grafts are
placed at the point of maximal lateral nasal wall collapse,
usually at the point of the supra-alar groove. As with
spreader grafts, these grafts can be applied through either
an endonasal incision or via the external rhinoplasty
approach. Once the graft is in position, there should be an
immediate improvement in support of the alar side walls
as well as diminution of alar collapse during inspiration
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Ryan M. Greene • Dean M. Toriumi
A
B
C
D
Figure 18-8 Patient with dorsal hump and
deep radix. Double layer radix graft placed into
narrow pocket over nasofrontal angle to augment
the radix and help create a straight dorsal profile.
Preoperative (A, C, E, and G) and postoperative
(B, D, F, and H) views.

through the nose. We use splints in the nasal vestibule to
support the alar battens and to help them heal in a lateral
position.
ACUTE NASOLABIAL ANGLE OR RETRACTED
COLUMELLA
Owing to posterior positioning of the feet of the medial
crura, the older patient frequently has an acute nasolabial
angle. Correction of this deformity adds support to the
medial crural component of the tripod complex and
improves the aesthetic appearance on lateral view. For
minor augmentation, 1- to 2-mm pieces of cartilage can
be placed into a small pocket between the feet of the
medial crura. This serves to support the lower lateral
cartilages, preserve tip projection, and correct an acute
nasolabial angle. With more significant deficiency of the
medial crura, more aggressive maneuvers may be
necessary. A sutured-in-place columellar strut may be
sufficient. In most patients, however, a caudal extension
graft will be necessary to support the nasal base and open
the nasolabial angle.
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297
G
H
E
F
Figure 18-8 Continued.

The caudal extension graft is set in the midline and
sutured between the medial crura. This maneuver moves
the medial crura caudally and corrects the acute
nasolabial angle or retracted columella.19 A straight piece
of septal cartilage is sutured to the stable caudal septum
with 5-0 clear nylon mattress sutures (Fig. 18-10). This
allows extension of the graft into a pocket between the
medial crura. The graft is then sutured between the medial
crura with 5-0 clear nylon sutures. During this maneuver,
care must be taken to set the proper tip projection,
rotation, and columellar show. A more rigid nasal tip with
less recoil results due to fixation of the medial crura to the
caudal extension graft. If this grafting technique is
planned, this rigidity and lack of recoil should be explained
to the patient prior to the procedure. In addition, this
graft may alter the length of the upper lip, which could
298
Ryan M. Greene • Dean M. Toriumi
A
C
B
Figure 18-10 A shows a short caudal septum. B shows the caudal
septal extension graft sutured in position. The graft is harvested with a
standard septoplasty. C is an intraoperative photograph showing the graft
sutured in place.
Figure 18-9 Alar batten graft applied into pocket caudal to existing
lateral crura to support lateral wall.

change the upper lip posture during smiling. This technique
may be coupled with a tip graft to optimize the overall
appearance of the lower third of the nose (Fig. 18-11).
Many older patients present with a hanging columella
deformity caused by loss of support or stretching of
fibrous connections between the caudal septum and
medial crura. Correction of this deformity may entail
trimming of the caudal margin of the nasal septum or
medial crura. This can also include excision of excess
vestibular skin between the caudal septum and medial
crura as well. If the caudal nasal septum is trimmed, there
may be a loss of nasal tip support. A better option to
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299
Figure 18-11 Patient with thick skin and
bulbous nasal tip. In this patient, a tip graft was
applied to increase tip projection. A caudal
extension graft was used to support the nasal base.
Preoperative (A, C, E, and G) and postoperative (B,
D, F, and H) views.
A
B
C
D